1
|
Berisha G, Kvenshagen LN, Boldingh AM, Nakstad B, Blakstad E, Rønnestad AE, Solevåg AL. Video-Recorded Airway Suctioning of Clear and Meconium-Stained Amniotic Fluid and Associated Short-Term Outcomes in Moderately and Severely Depressed Preterm and Term Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 11:16. [PMID: 38255330 PMCID: PMC10814005 DOI: 10.3390/children11010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The aim of this study was to investigate delivery room airway suctioning and associated short-term outcomes in depressed infants. METHODS This is a single-centre prospective observational study of transcribed video recordings of preterm (gestational age, GA < 37 weeks) and term (GA ≥ 37 weeks) infants with a 5 min Apgar score ≤ 7. We analysed the association between airway suctioning, breathing, bradycardia and prolonged resuscitation (≥10 min). For comparison, non-suctioned infants with a 5 min Apgar score ≤ 7 were included. RESULTS Two hundred suction episodes were performed in 19 premature and 56 term infants. Breathing improved in 1.9% of premature and 72.1% of term infants, and remained unchanged in 84.9% of premature and 27.9% of term infants after suctioning. In our study, 61 (81.3%) preterm and term infants who were admitted to the neonatal intensive care unit experienced bradycardia after airway suctioning. However, the majority of the preterm and more than half of the term infants were bradycardic before the suction procedure was attempted. Among the non-airway suctioned infants (n = 26), 73.1% experienced bradycardia, with 17 non-airway suctioned infants being admitted to the neonatal intensive care unit. There was a need for resuscitation ≥ 10 min in 8 (42.1%) preterm and 32 (57.1%) term infants who underwent airway suctioning, compared to 2 (33.3%) preterm and 19 (95.0%) term infants who did not receive airway suctioning. CONCLUSIONS In the infants that underwent suctioning, breathing improved in most term, but not preterm infants. More non-suctioned term infants needed prolonged resuscitation. Airway suctioning was not directly associated with worsening of breathing, bradycardia, or extended resuscitation needs.
Collapse
Affiliation(s)
- Gazmend Berisha
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway; (A.M.B.); (E.B.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- The Department of Anaesthesia and Intensive Care Unit, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
| | - Line Norman Kvenshagen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- Department of Paediatrics and Adolescent Medicine, Østfold Hospital Trust Kalnes, P.O. Box 300, 1714 Grålum, Norway
| | - Anne Marthe Boldingh
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway; (A.M.B.); (E.B.)
| | - Britt Nakstad
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- Department of Paediatrics and Adolescent Health, University of Botswana, Private Bag, Gaborone 0022, Botswana
| | - Elin Blakstad
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway; (A.M.B.); (E.B.)
| | - Arild Erland Rønnestad
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P.O. Box 4950, 0424 Oslo, Norway;
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P.O. Box 4950, 0424 Oslo, Norway;
| |
Collapse
|
2
|
Berisha G, Boldingh AM, Nakstad B, Blakstad EW, Rønnestad AE, Lee Solevåg A. Retrospectively Assessed Muscle Tone and Skin Colour following Airway Suctioning in Video-Recorded Infants Receiving Delivery Room Positive Pressure Ventilation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010166. [PMID: 36670716 PMCID: PMC9856869 DOI: 10.3390/children10010166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/24/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
Background: Recently, the International Liaison Committee on Resuscitation published a systematic review that concluded that routine suctioning of clear amniotic fluid in the delivery room might be associated with lower oxygen saturation (SpO2) and 10 min Apgar score. The aim of this study was to examine the effect of delivery room airway suctioning on the clinical appearance, including muscle tone and skin colour, of video-recorded term and preterm infants born through mainly clear amniotic fluid. Methods: This was a single-centre observational study using transcribed video recordings of neonatal stabilizations. All infants who received delivery room positive pressure ventilation (PPV) from August 2014 to November 2016 were included. The primary outcome was the effect of airway suctioning on muscle tone and skin colour (rated 0−2 according to the Apgar score), while the secondary outcome was the fraction of infants for whom airway suction preceded the initiation of PPV as a surrogate for “routine” airway suctioning. Results: Airway suctioning was performed in 159 out of 302 video recordings and stimulated a vigorous cry in 47 (29.6%) infants, resulting in improvements in muscle tone (p = 0.09) and skin colour (p < 0.001). In 43 (27.0%) infants, airway suctioning preceded the initiation of PPV. Conclusions: In this single-centre observational study, airway suctioning stimulated a vigorous cry with resulting improvements in muscle tone and skin colour. Airway suctioning was often performed prior to the initiation of PPV, indicating a practice of routine suctioning and guideline non-compliance.
Collapse
Affiliation(s)
- Gazmend Berisha
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway
- The Department of Anaesthesia and Intensive Care Unit, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
- Correspondence: ; Tel.: +47-99022121
| | - Anne Marthe Boldingh
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway
| | - Britt Nakstad
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway
- Department of Paediatrics and Adolescent Health, University of Botswana, Private Bag, Gaborone 0022, Botswana
| | - Elin Wahl Blakstad
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway
| | - Arild Erland Rønnestad
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P.O. Box 4950, 0424 Oslo, Norway
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P.O. Box 4950, 0424 Oslo, Norway
| |
Collapse
|
3
|
Bruschettini M, O'Donnell CPF, Davis PG, Morley CJ, Moja L, Calevo MG. Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes. Cochrane Database Syst Rev 2020; 3:CD004953. [PMID: 32187656 PMCID: PMC7080446 DOI: 10.1002/14651858.cd004953.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable gas exchange. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs. OBJECTIVES To assess the benefits and harms of an initial sustained lung inflation (SLI) (> 1 second duration) versus standard inflations (≤ 1 second) in newborn infants receiving resuscitation with intermittent PPV. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3), MEDLINE via PubMed (1966 to 1 April 2019), Embase (1980 to 1 April 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 1 April 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth. DATA COLLECTION AND ANALYSIS We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean standard deviation (SD), and weighted mean difference (WMD) for continuous data. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS Ten trials enrolling 1467 infants met our inclusion criteria. Investigators in nine trials (1458 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review: mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40 (I² not applicable); typical RD 0.00, 95% CI -0.02 to 0.02; I² = 0%; 5 studies, 479 participants); and mortality during hospitalisation (typical RR 1.09, 95% CI 0.83 to 1.43; I² = 42%; typical RD 0.01, 95% CI -0.02 to 0.04; I² = 24%; 9 studies, 1458 participants). The quality of the evidence was low for death in the delivery room because of limitations in study design and imprecision of estimates (only one death was recorded across studies). For death before discharge the quality was moderate: with longer follow-up there were more deaths (n = 143) but limitations in study design remained. Among secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; I² = 95%; 5 studies, 524 participants; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study at high risk of bias: when this study was removed from the analysis, the size of the effect was reduced (MD -1.71 days, 95% CI -3.04 to -0.39; I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. risk of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.91, 95% CI 0.79 to 1.04; I² = 65%; 5 studies, 811 participants); risk of surfactant administration during hospital admission (typical RR 0.99, 95% CI 0.91 to 1.08; I² = 0%; 9 studies, 1458 participants); risk of chronic lung disease (typical RR 0.99, 95% CI 0.83 to 1.18; I² = 0%; 4 studies, 735 participants); pneumothorax (typical RR 0.89, 95% CI 0.57 to 1.40; I² = 34%; 8 studies, 1377 infants); or risk of patent ductus arteriosus requiring pharmacological treatment (typical RR 0.99, 95% CI 0.87 to 1.12; I² = 48%; 7 studies, 1127 infants). The quality of evidence for these secondary outcomes was moderate (limitations in study design ‒ GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates ‒ GRADE). We could not perform any meta-analysis in the comparison of the use of initial sustained inflation versus standard inflations in newborns receiving resuscitation with chest compressions because we identified only one trial for inclusion (a pilot study of nine preterm infants). AUTHORS' CONCLUSIONS Our meta-analysis of nine studies shows that sustained lung inflation without chest compression was not better than intermittent ventilation for reducing mortality in the delivery room (low-quality evidence ‒ GRADE) or during hospitalisation (moderate-quality evidence ‒ GRADE), which were the primary outcomes of this review. However, the single largest study, which was well conducted and had the greatest number of enrolled infants, was stopped early for higher mortality rate in the sustained inflation group. When considering secondary outcomes, such as rate of intubation, rate or duration of respiratory support, or bronchopulmonary dysplasia, we found no benefit of sustained inflation over intermittent ventilation (moderate-quality evidence ‒ GRADE). Duration of mechanical ventilation was shortened in the SLI group (low-quality evidence ‒ GRADE); this result should be interpreted cautiously, however, as it might have been influenced by study characteristics other than the intervention. There is no evidence to support the use of sustained inflation based on evidence from our review.
Collapse
Affiliation(s)
- Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, first floorroom 11‐221LundSweden22185
| | - Colm PF O'Donnell
- National Maternity HospitalDepartment of NeonatologyHolles StreetDublin 2Ireland
| | - Peter G Davis
- The Royal Women’s HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Children's Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
| | - Colin J Morley
- University of CambridgeDepartment of Obstetrics and GynecologyCambridgeUK
| | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanMilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics Unit, IRCCSGenoaItaly16147
| | | |
Collapse
|
4
|
Umphrey L, Breindahl M, Brown A, Saugstad OD, Thio M, Trevisanuto D, Roehr CC, Blennow M. When Helping Babies Breathe Is Not Enough: Designing a Novel, Mid-Level Neonatal Resuscitation Algorithm for Médecins Sans Frontières Field Teams Working in Low-Resource Hospital Settings. Neonatology 2018; 114:112-123. [PMID: 29804116 PMCID: PMC6159832 DOI: 10.1159/000486705] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neonatal resuscitation (NR) combines a set of life-saving interventions in order to stabilize compromised newborns at birth or when critically ill. Médecins Sans Frontières/Doctors Without Borders (MSF), as an international medical-humanitarian organization working particularly in low-resource settings (LRS), assisted over 250,000 births in obstetric and newborn care aid projects in 2016 and provides thousands of newborn resuscitations annually. The Helping Babies Breathe (HBB) program has been used as formal guidance for basic resuscitation since 2012. However, in some MSF projects with the capacity to provide more advanced NR interventions but a lack of adapted guidance, staff have felt prompted to create their own advanced algorithms, which runs counter to the organization's aim for standardized protocols in all aspects of its care. OBJECTIVES The aim is to close a significant gap in neonatal care provision in LRS by establishing consensus on a protocol that would guide MSF field teams in their practice of more advanced NR. METHODS An independent committee of international experts was formed and met regularly from June 2016 to agree on the content and design of a new NR algorithm. RESULTS Consensus was reached on a novel, mid-level NR algorithm in April 2017. The algorithm was accepted for use by MSF Operational Center Paris. CONCLUSION This paper contributes to the literature on decision-making in the development of cognitive aids. The authors also highlight how critical gaps in healthcare delivery in LRS can be addressed, even when there is limited evidence to guide the process.
Collapse
Affiliation(s)
- Lisa Umphrey
- Medical Department, Médecins Sans Frontières Operational Centre Paris, Paris, France
| | - Morten Breindahl
- Department of Neonatology, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Alexandra Brown
- Communications Department, Médecins Sans Frontières, Sydney, New South Wales, Australia
| | - Ola Didrik Saugstad
- Department of Pediatric Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marta Thio
- Newborn Research Centre, The Royal Women's Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Charles Christoph Roehr
- Department of Paediatrics, Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, University of Oxford, Oxford, United Kingdom
| | - Mats Blennow
- Department of Neonatology, Karolinska Institutet and University Hospital, Stockholm, Sweden
| |
Collapse
|
5
|
Bruschettini M, O'Donnell CPF, Davis PG, Morley CJ, Moja L, Zappettini S, Calevo MG. Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes. Cochrane Database Syst Rev 2017; 7:CD004953. [PMID: 28707404 PMCID: PMC6483306 DOI: 10.1002/14651858.cd004953.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable effective breathing. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs. OBJECTIVES To assess the efficacy of an initial sustained (> 1 second duration) lung inflation versus standard inflations (≤ 1 second) in newly born infants receiving resuscitation with intermittent PPV. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1), MEDLINE via PubMed (1966 to 17 February 2017), Embase (1980 to 17 February 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 17 February 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth. DATA COLLECTION AND ANALYSIS We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and weighted mean difference (WMD) for continuous data. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS Eight trials enrolling 941 infants met our inclusion criteria. Investigators in seven trials (932 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review - mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40; participants = 479; studies = 5; I² not applicable) and mortality during hospitalisation (typical RR 1.01, 95% CI 0.67 to 1.51; participants = 932; studies = 7; I² = 19%); the quality of the evidence was low for death in the delivery room (limitations in study design and imprecision of estimates) and was moderate for death before discharge (limitations in study design of most included trials). Amongst secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; participants = 524; studies = 5; I² = 95%; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study: When this study was removed from the analysis, the effect was largely reduced (MD -1.71 days, 95% CI -3.04 to -0.39, I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. rate of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.93, 95% CI 0.79 to 1.09; participants = 811; studies = 5; I² = 0%); need for surfactant administration during hospital admission (typical RR 0.97, 95% CI 0.86 to 1.10; participants = 932; studies = 7; I² = 0%); rate of chronic lung disease (typical RR 0.95, 95% CI 0.74 to 1.22; participants = 683; studies = 5; I² = 47%); pneumothorax (typical RR 1.44, 95% CI 0.76 to 2.72; studies = 6, 851 infants; I² = 26%); or rate of patent ductus arteriosus requiring pharmacological treatment (typical RR 1.08, 95% CI 0.90 to 1.30; studies = 6, 745 infants; I² = 36%). The quality of evidence for these secondary outcomes was moderate (limitations in study design of most included trials - GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates - GRADE). AUTHORS' CONCLUSIONS Sustained inflation was not better than intermittent ventilation for reducing mortality in the delivery room and during hospitalisation. The number of events across trials was limited, so differences cannot be excluded. When considering secondary outcomes, such as need for intubation, need for or duration of respiratory support, or bronchopulmonary dysplasia, we found no evidence of relevant benefit for sustained inflation over intermittent ventilation. The duration of mechanical ventilation was shortened in the SLI group. This result should be interpreted cautiously, as it can be influenced by study characteristics other than the intervention. Future RCTs should aim to enrol infants who are at higher risk of morbidity and mortality, should stratify participants by gestational age, and should provide more detailed monitoring of the procedure, including measurements of lung volume and presence of apnoea before or during the SLI.
Collapse
Affiliation(s)
| | - Colm PF O'Donnell
- National Maternity HospitalDepartment of NeonatologyHolles StreetDublin 2Ireland
| | | | - Colin J Morley
- University of CambridgeDepartment of Obstetrics and GynecologyCambridgeUK
| | | | | | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics and Committees UnitGenoaItaly16147
| |
Collapse
|