1
|
Tracy MB, Hinder M, Morakeas S, Lowe K, Priyadarshi A, Crott M, Boustred M, Culcer M. Randomised study of a new inline respiratory function monitor (Juno) to improve mask seal and delivered ventilation with neonatal manikins. Arch Dis Child Fetal Neonatal Ed 2024; 109:535-541. [PMID: 38336472 PMCID: PMC11347194 DOI: 10.1136/archdischild-2023-326256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/18/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Respiratory function monitors (RFMs) have been used extensively in manikin and infant studies yet have not become the standard of training. We report the outcomes of a new portable, lightweight RFM, the Juno, designed to show mask leak and deflation tidal volume to assist in positive pressure ventilation (PPV) competency training using manikins. METHODS Two leak-free manikins (preterm and term) were used. Participants provided PPV to manikins using two randomised devices, self-inflating bag (SIB) and T-piece resuscitator (TPR), with Juno display initially blinded then unblinded in four 90 s paired sequences, aiming for adequate chest wall rise and target minimal mask leak with appropriate target delivered volume when using the monitor. RESULTS 49 experienced neonatal staff delivered 15 569 inflations to the term manikin and 14 580 inflations to the preterm. Comparing blinded to unblinded RFM display, there were significant reductions in all groups in the number of inflations out of target range volumes (preterm: SIB 22.6-6.6%, TPR 7.1-4.2% and term: SIB 54.8-37.8%, TPR 67.2-63.8%). The percentage of mask leak inflations >60% was reduced in preterm: SIB 20.7-7.2%, TPR 23.4-7.4% and in term: SIB 8.7-3.6%, TPR 23.5-6.2%). CONCLUSIONS Using the Juno monitor during simulated resuscitation significantly improved mask leak and delivered ventilation among otherwise experienced staff using preterm and term manikins. The Juno is a novel RFM that may assist in teaching and self-assessment of resuscitation PPV technique.
Collapse
Affiliation(s)
- Mark Brian Tracy
- Westmead Hospital, Sydney, New South Wales, Australia
- Department of Paediatrics and Child Health, Sydney University, Sydney, New South Wales, Australia
| | - Murray Hinder
- Department of Paediatrics and Child Health, Sydney University, Sydney, New South Wales, Australia
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephanie Morakeas
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney University, Sydney, New South Wales, Australia
| | - Krista Lowe
- Newborn Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Archana Priyadarshi
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Matthew Crott
- Sydney University, Sydney, New South Wales, Australia
| | | | - Mihaela Culcer
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Dvorsky R, Bibl K, Lietz A, Haderer M, Klebermaß-Schrehof K, Werther T, Schmölzer GM, Berger A, Wagner M. Optimization of manual ventilation quality using respiratory function monitoring in neonates: A two-phase intervention trial. Resuscitation 2024:110345. [PMID: 39097079 DOI: 10.1016/j.resuscitation.2024.110345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 07/09/2024] [Accepted: 07/28/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVE The aim of this study was the evaluation of the impact of a respiratory function monitor (RFM, Neo100, Monivent AB, Gothenburg, Sweden) on the quality of ventilation in neonates. METHODS This single-center two-phase intervention study was conducted at the Neonatal Intensive Care Unit and the delivery room of the Medical University of Vienna. Patients with clinical need for positive pressure ventilation were included in either of two consecutive study phases: (i) patients were ventilated with a hidden RFM (control) or (ii) visible RFM (intervention) during manual positive pressure ventilations. The duration of each phase was approximately six months. The primary outcome was the percentage of ventilations within a tidal volume range of 4-8 ml/kg (pVTe). RESULTS A total of 90 patients (GA 22-66 weeks) were included. The primary outcome was significantly higher in the intervention group with a visible RFM (53.7%, SD 22.6) than in the control group without the monitor (37.3%, SD 20.5); (p < 0.001, mean difference [i.e., change in percentage points]: 16.95% CI: 7.4-35). In terms of secondary outcomes, excessive tidal volumes (>8ml/kg), potentially associated with an increased risk of brain injury, could be significantly reduced when a RFM was visible during ventilation (10.9% [IQR 26.4] vs. 29.5% [IQR 38.1]; p = 0.004). Furthermore, mask leakage could be significantly decreased (37.3% [SD 22.7] vs. 52.7% [SD 23.0]; p = 0.002). CONCLUSION Our results suggest that the clinical application of a RFM for manual ventilation of preterm and term infants leads to a significant improvement in ventilation parameters.
Collapse
Affiliation(s)
- Robyn Dvorsky
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katharina Bibl
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andrea Lietz
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Moritz Haderer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katrin Klebermaß-Schrehof
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
3
|
Tran KH, Ramsie M, Law B, Schmölzer G. Comparison of positive pressure ventilation devices during compliance changes in a neonatal ovine model. Pediatr Res 2024; 96:332-337. [PMID: 38218928 DOI: 10.1038/s41390-024-03028-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/14/2023] [Accepted: 12/29/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND To compare tidal volume (VT) delivery with compliance at 0.5 and 1.5 mL/cmH2O using four different ventilation (PPV) devices (i.e., self-inflating bag (SIB), T-Piece resuscitator, Next Step (a novel Neonatal Resuscitator), and Fabian ventilator (conventional neonatal ventilator) using a neonatal piglet model. DESIGN/METHODS Randomized experimental animal study using 10 mixed-breed neonatal piglets (1-3 days; 1.8-2.4 kg). Piglets were anesthetized, intubated, instrumented, and randomized to receive positive pressure ventilation (PPV) for one minute with a SIB with or without a respiratory function monitor (RFM), T-Piece resuscitator with or without an RFM, Next Step, and Fabian Ventilator with both compliance levels. Compliance changes were achieved by placing a wrap around the piglets' chest and tightened it. Our primary outcome was targeted VT delivery of 5 mL/kg at 0.5 and 1.5 mL/cmH2O lung compliance. RESULTS At 0.5 mL/cmH2O compliance, the mean(SD) expired VT with the Next Step was 5.1(0.2) mL/kg compared to the Fabian 4.8(0.5) mL/kg, SIB 8.9(3.6) mL/kg, SIB + RFM 4.5(1.8) mL/kg, T-Piece 7.4(4.3) mL/kg, and T-Piece+RFM 6.4(3.1) mL/kg. At 1.5 mL/cmH2O compliance, the mean(SD) expired VT with the Next Step was 5.2(0.6) mL/kg compared to the Fabian 4.4(0.7) mL/kg, SIB 12.1(5.3) mL/kg, SIB + RFM 9.4(3.9) mL/kg, T-Piece 8.6(1.5) mL/kg, and T-Piece+RFM 6.5 (1.6) mL/kg. CONCLUSION The Next Step provides consistent VT during PPV, which is comparable to a mechanical ventilator. IMPACT Current guidelines recommend fixed peak inflation pressure in resuscitation, linked to lung and brain injury. The Next Step Neonatal Resuscitator, a cost-effective device, offers volume-targeted positive pressure ventilation with consistent tidal volumes. With two different compliances, the Next Step Neonatal Resuscitator delivered a consistent tidal volume which was similar to a mechanical ventilator. The Next Step Neonatal Resuscitator outperformed self-inflating bags and T-Pieces in delivering targeted tidal volumes. The Next Step Neonatal Resuscitator could be an alternative ventilation device for neonatal resuscitation.
Collapse
Affiliation(s)
- Kim Hoang Tran
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marwa Ramsie
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Brenda Law
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Georg Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
4
|
Ducatez F, Tebani A, Abily-Donval L, Snanoudj S, Pilon C, Plichet T, Le Chatelier C, Bekri S, Marret S. New insights and potential biomarkers for intraventricular hemorrhage in extremely premature infant, case-control study. Pediatr Res 2024; 96:395-401. [PMID: 38467704 DOI: 10.1038/s41390-024-03111-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Despite advancements in neonatal care, germinal matrix-intraventricular hemorrhage impacts 20% of very preterm infants, exacerbating their neurological prognosis. Understanding its complex, multifactorial pathophysiology and rapid onset remains challenging. This study aims to link specific cord blood biomolecules at birth with post-natal germinal matrix-intraventricular hemorrhage onset. METHODS A monocentric, prospective case-control study was conducted at Rouen University Hospital from 2015 to 2020. Premature newborns ( < 30 gestational age) were included and cord blood was sampled in the delivery room. A retrospective matching procedure was held in 2021 to select samples for proteomic and metabolomic analysis of 370 biomolecules. RESULTS 26 patients with germinal matrix-intraventricular hemorrhage cases and 60 controls were included. Clinical differences were minimal, except for higher invasive ventilation rates in the germinal matrix-intraventricular hemorrhage group. Germinal matrix-intraventricular hemorrhage newborns exhibited lower phosphatidylcholine levels and elevated levels of four proteins: BOC cell adhesion-associated protein, placental growth factor, Leukocyte-associated immunoglobulin-like receptor 2, and tumor necrosis factor-related apoptosis-inducing ligand receptor 2. CONCLUSION This study identifies biomolecules that may be linked to subsequent germinal matrix-intraventricular hemorrhage, suggesting heightened vascular disruption risk as an independent factor. These results need further validation but could serve as early germinal matrix-intraventricular hemorrhage risk biomarkers for future evaluations. IMPACT Decrease in certain phosphatidylcholines and increase in four proteins in cord blood at birth may be linked to subsequent germinal matrix-intraventricular hemorrhage in premature newborns. The four proteins are BOC cell adhesion-associated protein, placental growth factor, leukocyte-associated immunoglobulin-like receptor 2, and TNF-related apoptosis-inducing ligand receptor 2. This biological imprint could point toward higher vascular disruption risk as an independent risk factor for this complication and with further validations, could be used for better stratification of premature newborns at birth.
Collapse
Affiliation(s)
- Franklin Ducatez
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, 76000, Rouen, France
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Metabolic Biochemistry, 76000, Rouen, France
| | - Abdellah Tebani
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Metabolic Biochemistry, 76000, Rouen, France
| | - Lenaig Abily-Donval
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, 76000, Rouen, France
| | - Sarah Snanoudj
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Metabolic Biochemistry, 76000, Rouen, France
| | - Carine Pilon
- CHU Rouen, Department of Metabolic Biochemistry, 76000, Rouen, France
| | - Thomas Plichet
- CHU Rouen, Department of Metabolic Biochemistry, 76000, Rouen, France
| | - Charlotte Le Chatelier
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, 76000, Rouen, France
| | - Soumeya Bekri
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Metabolic Biochemistry, 76000, Rouen, France
| | - Stéphane Marret
- Normandie Univ, UNIROUEN, INSERM U1245, CHU Rouen, Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, 76000, Rouen, France.
| |
Collapse
|
5
|
Tran NT, Penny TR, Chan KY, Tang T, Papagianis PC, Sepehrizadeh T, Nekkanti L, Zahra VA, Pham Y, Yawno T, Nitsos I, Kelly SB, Thiel AM, de Veer M, Alahmari DM, Fahey MC, Jenkin G, Miller SL, Galinsky R, Polglase GR, McDonald CA. Early administration of umbilical cord blood cells following brief high tidal volume ventilation in preterm sheep: a cautionary tale. J Neuroinflammation 2024; 21:121. [PMID: 38720368 PMCID: PMC11077893 DOI: 10.1186/s12974-024-03053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/23/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Umbilical cord blood (UCB) cells are a promising treatment for preterm brain injury. Access to allogeneic sources of UCB cells offer the potential for early administration to optimise their therapeutic capacities. As preterm infants often require ventilatory support, which can contribute to preterm brain injury, we investigated the efficacy of early UCB cell administration following ventilation to reduce white matter inflammation and injury. METHODS Preterm fetal sheep (0.85 gestation) were randomly allocated to no ventilation (SHAM; n = 5) or 15 min ex utero high tidal volume ventilation. One hour following ventilation, fetuses were randomly allocated to i.v. administration of saline (VENT; n = 7) or allogeneic term-derived UCB cells (24.5 ± 5.0 million cells/kg; VENT + UCB; n = 7). Twenty-four hours after ventilation, lambs were delivered for magnetic resonance imaging and post-mortem brain tissue collected. Arterial plasma was collected throughout the experiment for cytokine analyses. To further investigate the results from the in vivo study, mononuclear cells (MNCs) isolated from human UCB were subjected to in vitro cytokine-spiked culture medium (TNFα and/or IFNγ; 10 ng/mL; n = 3/group) for 16 h then supernatant and cells collected for protein and mRNA assessments respectively. RESULTS In VENT + UCB lambs, systemic IFNγ levels increased and by 24 h, there was white matter neuroglial activation, vascular damage, reduced oligodendrocytes, and increased average, radial and mean diffusivity compared to VENT and SHAM. No evidence of white matter inflammation or injury was present in VENT lambs, except for mRNA downregulation of OCLN and CLDN1 compared to SHAM. In vitro, MNCs subjected to TNFα and/or IFNγ displayed both pro- and anti-inflammatory characteristics indicated by changes in cytokine (IL-18 & IL-10) and growth factor (BDNF & VEGF) gene and protein expression compared to controls. CONCLUSIONS UCB cells administered early after brief high tidal volume ventilation in preterm fetal sheep causes white matter injury, and the mechanisms underlying these changes are likely dysregulated responses of the UCB cells to the degree of injury/inflammation already present. If immunomodulatory therapies such as UCB cells are to become a therapeutic strategy for preterm brain injury, especially after ventilation, our study suggests that the inflammatory state of the preterm infant should be considered when timing UCB cells administration.
Collapse
Affiliation(s)
- Nhi T Tran
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.
| | - Tayla R Penny
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Kyra Yy Chan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Tanya Tang
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Paris C Papagianis
- Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Tara Sepehrizadeh
- Monash Biomedical Imaging, Monash University, Clayton, VIC, Australia
| | - Lakshmi Nekkanti
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Valerie A Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Sharmony B Kelly
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Alison M Thiel
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Michael de Veer
- Monash Biomedical Imaging, Monash University, Clayton, VIC, Australia
| | - Dhafer M Alahmari
- Monash Biomedical Imaging, Monash University, Clayton, VIC, Australia
- Monash Biomedicine Discovery Institute and Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
- Department of Diagnostic Imaging, Kind Saud Medical City, Riyadh, Saudi Arabia
| | - Michael C Fahey
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.
| | - Courtney A McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.
| |
Collapse
|
6
|
Diggikar S, Ramaswamy VV, Koo J, Prasath A, Schmölzer GM. Positive Pressure Ventilation in Preterm Infants in the Delivery Room: A Review of Current Practices, Challenges, and Emerging Technologies. Neonatology 2024; 121:288-297. [PMID: 38467119 DOI: 10.1159/000537800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND A major proportion of preterm neonates require positive pressure ventilation (PPV) immediately after delivery. PPV may be administered through a face mask (FM) or nasal prongs. Current literature indicates that either of these are associated with similar outcomes. SUMMARY Nonetheless, FM remains the most utilized and the best choice. However, most available FM sizes are too large for extremely preterm infants, which leads to mask leak and ineffective PPV. Challenges to providing effective PPV include poor respiratory drive, complaint chest wall, weak thoracic muscle, delayed liquid clearance, and surfactant deficiency in preterm infants. Mask leak, airway obstruction, poor technique, and inappropriate size are correctable causes of ineffective PPV. Visual assessment of chest rise is often used to assess the efficacy of PPV. However, its accuracy is debatable. Though end tidal CO2 may adjudge the effectiveness of PPV, clinical studies are limited. The compliance of a preterm lung is highly dynamic. The inflating pressure set on T-piece is constant throughout the resuscitation, but the lung volume and dynamics changes with every breath. This leads to huge fluctuations of tidal volume delivery and can trigger inflammatory cascade in preterm infants leading to brain and lung injury. Respiratory function monitoring in the delivery room has potential for guiding and optimizing delivery room resuscitation. This is, however, limited by high costs, complex information that is difficult to interpret during resuscitation, and absence of clinical trials. KEY MESSAGES This review summarizes the existing literature on PPV in preterm infants, the various aspects related to it such as the pathophysiology, interfaces, devices utilized to deliver it, appropriate technique, emerging technologies, and future directions.
Collapse
Affiliation(s)
| | | | - Jenny Koo
- Sharp Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Arun Prasath
- Department of Neonatal-Perinatal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
7
|
Koo J, Cheung PY, Pichler G, Solevåg AL, Law BHY, Katheria AC, Schmölzer GM. Chest compressions superimposed with sustained inflation during neonatal cardiopulmonary resuscitation: are we ready for a clinical trial? Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326769. [PMID: 38453436 DOI: 10.1136/archdischild-2023-326769] [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: 12/15/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024]
Abstract
Neonates requiring cardiopulmonary resuscitation (CPR) are at risk of mortality and neurodevelopmental injury. Poor outcomes following the need for chest compressions (CCs) in the delivery room prompt the critical need for improvements in resuscitation strategies. This article explores a technique of CPR which involves CCs with sustained inflation (CC+SI). Unique features of CC+SI include (1) improved tidal volume delivery, (2) passive ventilation during compressions, (3) uninterrupted compressions and (4) improved stability of cerebral blood flow during resuscitation. CC+SI has been shown in animal studies to have improved time to return of spontaneous circulation and reduced mortality without significant increase in markers of inflammation and injury in the lung and brain, compared with standard CPR. The mechanics of CCs, rate of compressions, ventilation strategies and compression-to-ventilation ratios are detailed here. A large randomised controlled trial comparing CC+SI versus the current 3:1 compression-to-ventilation ratio is needed, given the growing evidence of its potential benefits.
Collapse
Affiliation(s)
- Jenny Koo
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Anne Lee Solevåg
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Brenda Hiu Yan Law
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | | |
Collapse
|
8
|
Azman Z, Vidinopoulos K, Somers A, Hooper SB, Zahra VA, Thiel AM, Galinsky R, Tran NT, Allison BJ, Polglase GR. In utero ventilation induces lung parenchymal and vascular alterations in extremely preterm fetal sheep. Am J Physiol Lung Cell Mol Physiol 2024; 326:L330-L343. [PMID: 38252635 DOI: 10.1152/ajplung.00249.2023] [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] [Received: 08/04/2023] [Revised: 12/19/2023] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
Extremely preterm infants are often exposed to long durations of mechanical ventilation to facilitate gas exchange, resulting in ventilation-induced lung injury (VILI). New lung protective strategies utilizing noninvasive ventilation or low tidal volumes are now common but have not reduced rates of bronchopulmonary dysplasia. We aimed to determine the effect of 24 h of low tidal volume ventilation on the immature lung by ventilating preterm fetal sheep in utero. Preterm fetal sheep at 110 ± 1(SD) days' gestation underwent sterile surgery for instrumentation with a tracheal loop to enable in utero mechanical ventilation (IUV). At 112 ± 1 days' gestation, fetuses received either in utero mechanical ventilation (IUV, n = 10) targeting 3-5 mL/kg for 24 h, or no ventilation (CONT, n = 9). At necropsy, fetal lungs were collected to assess molecular and histological markers of lung inflammation and injury. IUV significantly increased lung mRNA expression of interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF) compared with CONT, and increased surfactant protein (SP)-A1, SP-B, and SP-C mRNA expression compared with CONT. IUV produced modest structural changes to the airways, including reduced parenchymal collagen and myofibroblast density. IUV increased pulmonary arteriole thickness compared with CONT but did not alter overall elastin or collagen content within the vasculature. In utero ventilation of an extremely preterm lung, even at low tidal volumes, induces lung inflammation and injury to the airways and vasculature. In utero ventilation may be an important model to isolate the confounding mechanisms of VILI to develop effective therapies for preterm infants requiring prolonged respiratory support.NEW & NOTEWORTHY Preterm infants often require prolonged respiratory support, but the relative contribution of ventilation to the development of lung injury is difficult to isolate. In utero mechanical ventilation allows for mechanistic investigations into ventilation-induced lung injury without confounding factors associated with sustaining extremely preterm lambs ex utero. Twenty-four hours of in utero ventilation, even at low tidal volumes, increased lung inflammation and surfactant protein expression and produced structural changes to the lung parenchyma and vasculature.
Collapse
Affiliation(s)
- Zahrah Azman
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Kayla Vidinopoulos
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Ainsley Somers
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Valerie A Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Alison M Thiel
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Nhi T Tran
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
9
|
Hillman NH, Jobe AH. Preterm lung and brain responses to mechanical ventilation and corticosteroids. J Perinatol 2023; 43:1222-1229. [PMID: 37169913 DOI: 10.1038/s41372-023-01692-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/13/2023]
Abstract
Mechanical ventilation is necessary to maintain oxygenation and ventilation in many preterm infants. Unfortunately, even short periods of mechanical ventilation can cause lung and airway injury, and initiate the lung inflammation that contributes to the development of bronchopulmonary dysplasia (BPD). The mechanical stretch leads to airway cell differentiation and simplification of the alveoli, and releases cytokines that cause systemic response in other organs. Mechanical ventilation also leads to brain injury (IVH, white and gray matter) and neuronal inflammation that can affect the neurodevelopment of preterm infants. In efforts to decrease BPD, corticosteroids have been used for both prevention and treatment of lung inflammation. Corticosteroids have also been demonstrated to cause neuronal injury, so the clinician must balance the negative effects of both mechanical ventilation and steroids on the brain and lungs. Predictive models for BPD can help assess the infants who will benefit most from corticosteroid exposure. This review describes the lung and brain injury from mechanical ventilation in the delivery room and chronic mechanical ventilation in animal models. It provides updates on the current guidelines for use of postnatal corticosteroids (dexamethasone, hydrocortisone, budesonide, budesonide with surfactant) for the prevention and treatment of BPD, and the effects the timing of each steroid regimen has on neurodevelopment.
Collapse
Affiliation(s)
- Noah H Hillman
- Division of Neonatology, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, MO, 63104, USA.
| | - Alan H Jobe
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, 45229, USA
| |
Collapse
|
10
|
Gunawardana S, Arattu Thodika FMS, Murthy V, Bhat P, Williams EE, Dassios T, Milner AD, Greenough A. Respiratory function monitoring during early resuscitation and prediction of outcomes in prematurely born infants. J Perinat Med 2023; 51:950-955. [PMID: 36800988 DOI: 10.1515/jpm-2022-0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/25/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVES Over the last decade, there has been increased use of end-tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) monitoring during resuscitation of prematurely born infants in the delivery suite. Our objectives were to test the hypotheses that low end-tidal carbon dioxide (ETCO2) levels, low oxygen saturations (SpO2) and high expiratory tidal volumes (VTE) during the early stages of resuscitation would be associated with adverse outcomes in preterm infants. METHODS Respiratory recordings made in the first 10 min of resuscitation in the delivery suite of 60 infants, median GA 27 (interquartile range 25-29) weeks were analysed. The results were compared of infants who did or did not die or did or did not develop intracerebral haemorrhage (ICH) or bronchopulmonary dysplasia (BPD). RESULTS Twenty-five infants (42%) developed an ICH and 23 (47%) BPD; 11 (18%) died. ETCO2 at approximately 5 min after birth was lower in infants who developed an ICH, this remained significant after adjusting for gestational age, coagulopathy and chorioamnionitis (p=0.03). ETCO2 levels were lower in infants who developed ICH or died compared to those that survived without ICH, which remained significant after adjustment for gestational age, Apgar score at 10 min, chorioamnionitis and coagulopathy (p=0.004). SpO2 at approximately 5 min was lower in the infants who died compared to those who survived which remained significant after adjusting for the 5-min Apgar score and chorioamnionitis (p=0.021). CONCLUSIONS ETCO2 and SpO2 levels during early resuscitation in the delivery suite were associated with adverse outcomes.
Collapse
Affiliation(s)
- Shannon Gunawardana
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fahad M S Arattu Thodika
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, Barts Health NHS Trust, London, UK
| | - Prashanth Bhat
- Neonatal Intensive Care Centre, Brighton and Sussex University Hospital, Sussex, UK
| | - Emma E Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| |
Collapse
|
11
|
Chen M, Xu Y, Guo X, Sun B. Efficacy of perinatal pharmacotherapeutic actions for survival of very preterm newborn rabbits at 26-day gestation. J Appl Physiol (1985) 2023; 134:558-568. [PMID: 36701481 DOI: 10.1152/japplphysiol.00606.2022] [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: 10/12/2022] [Revised: 12/28/2022] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
Investigation of the pathophysiology of lung impairment and protection in very preterm neonates at birth requires adequate experimental models. This study aimed to elucidate the efficacy and mechanism of perinatal pharmacotherapeutic action in postnatal survival of very preterm rabbits. Pregnant New Zealand White rabbits on 25-day gestation (term 31 days) were given dexamethasone (D), or sham injection as control (C), and cesarean delivered 24 hours later on day 26. Newborns were anesthetized, intratracheally intubated, randomly received either saline or porcine surfactant (S), allocated to four groups (C, S, D, and DS), and ventilated with low tidal volume. Under the identical protocol, another four groups were added with nitric oxide (N) inhalation (CN, SN, DN, and DSN). Survival length, lung mechanics, histopathology, and pathobiology of lung tissue were measured for benefits and injury patterns. DSN had the longest median survival time (ST50, 10.3 h), whereas C had the shortest (3.5 h), with remaining groups in-between. The survival was mainly benefited by S, when additive effects with D and/or N were discernible, by improved lung mechanics and alveolar aeration, ameliorated lung injury severity and pneumothorax, and augmented lung phospholipid pools, with DSN being the most optimal. Variable mRNA expression profiles of alveolar epithelia-associated cytokines and inflammatory mediators further characterized injury and response patterns as phenotyping conditioned in pharmacotherapeutic actions. In conclusion, the combined regimens of perinatal medications achieved remarkable survival in very preterm rabbits with lung protective ventilation strategy, offering a unique model in investigation of very preterm birth-associated respiratory physiology and morbidities.NEW & NOTEWORTHY By establishing a very preterm rabbit model with 26-day gestation (term 31 days), optimal survival length for 50% of animals in groups was achieved by comparing regimens of combined antenatal glucocorticoids, postnatal surfactant and inhaled nitric oxide, with a low tidal volume ventilation strategy. The efficacies of pharmacotherapeutic action were associated with significantly improved lung mechanics, ameliorated lung injury and pneumothorax, and enhanced surfactant phospholipid metabolism, along with variable mRNA expression profiles characterizing the response patterns.
Collapse
Affiliation(s)
- Meimei Chen
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| | - Yaling Xu
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| | - Xiaojing Guo
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| | - Bo Sun
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| |
Collapse
|
12
|
Escrig-Fernández R, Zeballos-Sarrato G, Gormaz-Moreno M, Avila-Alvarez A, Toledo-Parreño JD, Vento M. The Respiratory Management of the Extreme Preterm in the Delivery Room. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020351. [PMID: 36832480 PMCID: PMC9955623 DOI: 10.3390/children10020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.
Collapse
Affiliation(s)
- Raquel Escrig-Fernández
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
- Correspondence:
| | | | - María Gormaz-Moreno
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Alejandro Avila-Alvarez
- Division of Neonatology, Pediatric Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, 15006 A Coruña, Spain
| | - Juan Diego Toledo-Parreño
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Máximo Vento
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| |
Collapse
|
13
|
de Medeiros SM, Mangat A, Polglase GR, Sarrato GZ, Davis PG, Schmölzer GM. Respiratory function monitoring to improve the outcomes following neonatal resuscitation: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:589-596. [PMID: 35058279 DOI: 10.1136/archdischild-2021-323017] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/16/2021] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Animal and observational human studies report that delivery of excessive tidal volume (VT) at birth is associated with lung and brain injury. Using a respiratory function monitor (RFM) to guide VT delivery might reduce injury and improve outcomes. OBJECTIVE To determine whether use of an RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room reduces in-hospital mortality and morbidity of infants <37 weeks' gestation. STUDY SELECTION Randomised controlled trials (RCTs) comparing RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room of infants born <37 weeks' gestation. DATA ANALYSIS Risk of bias was assessed using Covidence Collaboration tool and pooled into a meta-analysis using a random-effects model. The primary outcome was death prior to discharge. MAIN OUTCOME Death before hospital discharge. RESULTS Three RCTs enrolling 443 infants were combined in a meta-analysis. The pooled analysis showed no difference in rates of death before discharge with an RFM versus no RFM, relative risk (RR) 95% (CI) 0.98 (0.64 to 1.48). The pooled analysis suggested a significant reduction for brain injury (a combination of intraventricular haemorrhage and periventricular leucomalacia) (RR 0.65 (0.48 to 0.89), p=0.006) and for intraventricular haemorrhage (RR 0.69 (0.50 to 0.96), p=0.03) in infants receiving positive pressure ventilation with an RFM versus no RFM. CONCLUSION In infants <37 weeks, an RFM in addition to clinical assessment compared with clinical assessment during mask ventilation resulted in similar in-hospital mortality, significant reduction for any brain injury and intraventricular haemorrhage. Further trials are required to determine whether RFMs should be routinely available for neonatal resuscitation.
Collapse
Affiliation(s)
- Sarah Marie de Medeiros
- Centre for the Studies of Asphyxia and Resuscitation, Neonatology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Avneet Mangat
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Peter G Davis
- Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatology, Royal Alexandra Hospital, Edmonton, Alberta, Canada .,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
14
|
Foglia EE, Shah BA, Szyld E. Positive pressure ventilation at birth. Semin Perinatol 2022; 46:151623. [PMID: 35697527 DOI: 10.1016/j.semperi.2022.151623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review the current state of the art of positive pressure ventilation (PPV) during resuscitation FINDINGS: The frequency of PPV during delivery room resuscitation varies across settings and gestational age subgroups. Goal targets and parameters for delivery room PPV remain undefined. The T-piece resuscitator provides the most consistent pressures during PPV and may improve clinical outcomes. The laryngeal mask may be an important alternative interface for PPV, but more data are needed to identify the optimal role of the supraglottic airway during PPV. No objective monitors of PPV have conclusively demonstrated improved outcomes to date. CONCLUSION More information, including real-world data from population-based studies, is needed to provide data-driven guidelines for positive pressure ventilation during neonatal transition after birth.
Collapse
Affiliation(s)
- Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia PA USA.
| | - Birju A Shah
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; College of Medicine, University of Oklahoma, Oklahoma City, OK, USA
| | - Edgardo Szyld
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; College of Medicine, University of Oklahoma, Oklahoma City, OK, USA
| |
Collapse
|
15
|
Knol R, Brouwer E, van den Akker T, DeKoninck PLJ, Lopriore E, Onland W, Vermeulen MJ, van den Akker-van Marle ME, van Bodegom-Vos L, de Boode WP, van Kaam AH, Reiss IKM, Polglase GR, Hutten GJ, Prins SA, Mulder EEM, Hulzebos CV, van Sambeeck SJ, van der Putten ME, Zonnenberg IA, Hooper SB, Te Pas AB. Physiological-based cord clamping in very preterm infants: the Aeration, Breathing, Clamping 3 (ABC3) trial-study protocol for a multicentre randomised controlled trial. Trials 2022; 23:838. [PMID: 36183143 PMCID: PMC9526936 DOI: 10.1186/s13063-022-06789-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International guidelines recommend delayed umbilical cord clamping (DCC) up to 1 min in preterm infants, unless the condition of the infant requires immediate resuscitation. However, clamping the cord prior to lung aeration may severely limit circulatory adaptation resulting in a reduction in cardiac output and hypoxia. Delaying cord clamping until lung aeration and ventilation have been established (physiological-based cord clamping, PBCC) allows for an adequately established pulmonary circulation and results in a more stable circulatory transition. The decline in cardiac output following time-based delayed cord clamping (TBCC) may thus be avoided. We hypothesise that PBCC, compared to TBCC, results in a more stable transition in very preterm infants, leading to improved clinical outcomes. The primary objective is to compare the effect of PBCC on intact survival with TBCC. METHODS The Aeriation, Breathing, Clamping 3 (ABC3) trial is a multicentre randomised controlled clinical trial. In the interventional PBCC group, the umbilical cord is clamped after the infant is stabilised, defined as reaching heart rate > 100 bpm and SpO2 > 85% while using supplemental oxygen < 40%. In the control TBCC group, cord clamping is time based at 30-60 s. The primary outcome is survival without major cerebral and/or intestinal injury. Preterm infants born before 30 weeks of gestation are included after prenatal parental informed consent. The required sample size is 660 infants. DISCUSSION The findings of this trial will provide evidence for future clinical guidelines on optimal cord clamping management in very preterm infants at birth. TRIAL REGISTRATION ClinicalTrials.gov NCT03808051. First registered on January 17, 2019.
Collapse
Affiliation(s)
- Ronny Knol
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands. .,Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Emma Brouwer
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.,Athena Institute, VU University, Amsterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Enrico Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | | | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sandra A Prins
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Estelle E M Mulder
- Department of Neonatology, Isala Women and Children's Hospital, Zwolle, The Netherlands
| | - Christian V Hulzebos
- Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Sam J van Sambeeck
- Department of Paediatrics, Maxima Medical Center, Veldhoven, The Netherlands
| | - Mayke E van der Putten
- Department of Paediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Inge A Zonnenberg
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
16
|
Thomann J, Rüegger CM, Gaertner VD, O'Currain E, Kamlin OF, Davis PG, Springer L. Tidal volumes during delivery room stabilization of (near) term infants. BMC Pediatr 2022; 22:543. [PMID: 36100886 PMCID: PMC9469594 DOI: 10.1186/s12887-022-03600-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND We sought to assess tidal volumes in (near) term infants during delivery room stabilization. METHODS Secondary analysis of a prospective study comparing two facemasks used for positive pressure ventilation (PPV) in newborn infants ≥ 34 weeks gestation. PPV was provided with a T-piece device with a PIP of 30 cmH2O and positive end-expiratory airway pressure of 5 cmH2O. Expired tidal volumes (Vt) were measured with a respiratory function monitor. Target range for Vt was defined to be 4 - 8 ml/kg. RESULTS Twenty-three infants with a median (IQR) gestational age of 38.1 (36.4 - 39.0) weeks received 1828 inflations with a median Vt of 4.6 (3.3 - 6.2) ml/kg. Median Vt was in the target range in 12 infants (52%), lower in 9 (39%) and higher in 2 (9%). Thirty-six (25-27) % of the inflations were in the target rage over the duration of PPV while 42 (25 - 65) % and 10 (3 - 33) % were above and below target range. CONCLUSIONS Variability of expiratory tidal volume delivered to term and late preterm infants was wide. Reliance on standard pressures and clinical signs may be insufficient to provide safe and effective ventilation in the delivery room. TRIAL REGISTRATION This is a secondary analysis of a prospectively registered randomized controlled trial (ACTRN12616000768493).
Collapse
Affiliation(s)
- Janine Thomann
- Department of Neonatology, Newborn Research, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Christoph M Rüegger
- Department of Neonatology, Newborn Research, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Vincent D Gaertner
- Department of Neonatology, Newborn Research, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Eoin O'Currain
- School of Medicine, University College Dublin and National Maternity Hospital Dublin, Dublin, Ireland
| | - Omar F Kamlin
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Laila Springer
- Department of Neonatology, University Clinic Tübingen, Tübingen, Germany
| |
Collapse
|
17
|
Gaertner VD, Rüegger CM, Bassler D, O'Currain E, Kamlin COF, Hooper SB, Davis PG, Springer L. Effects of tactile stimulation on spontaneous breathing during face mask ventilation. Arch Dis Child Fetal Neonatal Ed 2022; 107:508-512. [PMID: 34862191 DOI: 10.1136/archdischild-2021-322989] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/16/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We sought to determine the effect of stimulation during positive pressure ventilation (PPV) on the number of spontaneous breaths, exhaled tidal volume (VTe), mask leak and obstruction. DESIGN Secondary analysis of a prospective, randomised trial comparing two face masks. SETTING Single-centre delivery room study. PATIENTS Newborn infants ≥34 weeks' gestation at birth. METHODS Resuscitations were video recorded. Tactile stimulations during PPV were noted and the timing, duration and surface area of applied stimulus were recorded. Respiratory flow waveforms were evaluated to determine the number of spontaneous breaths, VTe, leak and obstruction. Variables were recorded throughout each tactile stimulation episode and compared with those recorded in the same time period immediately before stimulation. RESULTS Twenty of 40 infants received tactile stimulation during PPV and we recorded 57 stimulations during PPV. During stimulation, the number of spontaneous breaths increased (median difference (IQR): 1 breath (0-3); padj<0.001) and VTe increased (0.5 mL/kg (-0.5 to 1.7), padj=0.028), whereas mask leak (0% (-20 to 1), padj=0.12) and percentage of obstructed inflations (0% (0-0), padj=0.14) did not change, compared with the period immediately prior to stimulation. Increased duration of stimulation (padj<0.001) and surface area of applied stimulus (padj=0.026) were associated with a larger increase in spontaneous breaths in response to tactile stimulation. CONCLUSIONS Tactile stimulation during PPV was associated with an increase in the number of spontaneous breaths compared with immediately before stimulation without a change in mask leak and obstruction. These data inform the discussion on continuing stimulation during PPV in term infants. TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trial Registry (ACTRN12616000768493).
Collapse
Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Christoph Martin Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Eoin O'Currain
- School of Medicine, University College Dublin and National Maternity Hospital Dublin, Dublin, Ireland
| | - C Omar Farouk Kamlin
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Laila Springer
- Department of Neonatology, University Clinic Tubingen, Tubingen, Germany
| |
Collapse
|
18
|
Chan KYY, Tran NT, Papagianis PC, Zahra VA, Nitsos I, Moxham AM, LaRosa DA, McDonald C, Miller SL, Galinsky R, Alahmari DM, Stojanovska V, Polglase GR. Investigating Pathways of Ventilation Induced Brain Injury on Cerebral White Matter Inflammation and Injury After 24 h in Preterm Lambs. Front Physiol 2022; 13:904144. [PMID: 35860659 PMCID: PMC9289398 DOI: 10.3389/fphys.2022.904144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Initiation of respiratory support in the delivery room increases the risk and severity of brain injury in preterm neonates through two major pathways: an inflammatory pathway and a haemodynamic pathway. The relative contribution of each pathway on preterm brain injury is not known. We aimed to assess the role of the inflammatory and haemodynamic pathway on ventilation-induced brain injury (VIBI) in the preterm lamb. Fetal lambs (125 ± 1 day gestation) were exteriorised, instrumented and ventilated with a high tidal-volume (VT) injurious strategy for 15 min either with placental circulation intact to induce the inflammatory pathway only (INJINF; n = 7) or umbilical cord occluded to induce both the inflammatory and haemodynamic pathways (INJINF+HAE; n = 7). Sham controls were exteriorised but not ventilated (SHAM; n = 5) while unoperated controls (UNOP; n = 7) did not undergo fetal instrumentation. Fetuses were returned in utero following intervention and the ewe allowed to recover. Arterial blood gases and plasma were sampled periodically. Twenty-four hours following intervention, lambs were delivered and maintained on non-injurious ventilation for ∼40 min then brains were collected post-mortem for immunohistochemistry and RT-qPCR to assess inflammation, vascular pathology and cell death within white matter regions. Compared to INJINF lambs, INJINF+HAE lambs achieved a consistently higher VT during injurious ventilation and carotid blood flow was significantly lower than baseline by the end of ventilation. Throughout the 24 h recovery period, systemic arterial IL-6 levels of INJINF+HAE lambs were significantly higher than SHAM while there was no difference between INJINF and SHAM animals. At 24 h, mRNA expression levels of pro-inflammatory cytokines, tight junction proteins, markers of cell death, and histological injury indices of gliosis, blood vessel protein extravasation, oligodendrocyte injury and cell death were not different between groups. Injurious ventilation, irrespective of strategy, did not increase brain inflammation or injury 24 h later when compared to control animals. However, the haemodynamic pathway did influence carotid blood flow adaptations during injurious ventilation and increased systemic arterial IL-6 that may underlie long-term pathology. Future studies are required to further characterise the pathways and their long-term effects on VIBI.
Collapse
Affiliation(s)
- Kyra YY Chan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Nhi T. Tran
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Paris C. Papagianis
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Valerie A. Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Alison M. Moxham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Domenic A. LaRosa
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Courtney McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Dhafer M. Alahmari
- Monash Biomedicine Discovery Institute and Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
- Monash Biomedical Imaging, Monash University, Clayton, VIC, Australia
- Department of Diagnostic Imaging, King Saud Medical City, Riyadh, Saudi Arabia
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- *Correspondence: Graeme R. Polglase,
| |
Collapse
|
19
|
Abstract
Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.
Collapse
|
20
|
Khare C, Adhisivam B, Gupta A, Vaishnav D, Vishnu Bhat B. Evaluation of T-piece resuscitator in the delivery room management of pre-term neonates with respiratory distress syndrome in resource-limited settings: A pre-post intervention study. Trop Doct 2022; 52:262-269. [PMID: 35243942 DOI: 10.1177/00494755221076942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of our study was to evaluate the impact of the T-piece resuscitator in the delivery room management of pre-term neonates in a resource-limited setting. We compared the incidence rates of delivery room intubation, surfactant replacement therapy, pulmonary air leak syndrome, and pre-term very low birth weight infant mortality, before and after T-piece use. Bi-monthly neonatal resuscitation training sessions were conducted for healthcare providers during the study period. We emphasized hands-on experience with the T-piece resuscitator and delivery room early respiratory care practices during the post-intervention epoch. Our pre- and post-intervention data recorded statistically significant decline in delivery room intubations, a 32% decrease in surfactant replacement therapy, and a 57% decrease in air leaks in pre-term neonates. However, the use of T-piece resuscitator did not have a statistically significant effect on pre-term very low birth weight infant mortality.
Collapse
Affiliation(s)
- Chetan Khare
- Department of Neonatology, 390706All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.,Department of Neonatology, 29988Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Bethou Adhisivam
- Department of Neonatology, 29988Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Avantika Gupta
- Department of Obstetrics and Gynaecology, 534693All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Dheeraj Vaishnav
- Department of Neonatology, 155196Geetanjali Institute of Medical Sciences, Udaipur, Rajasthan, India
| | - Ballambattu Vishnu Bhat
- Department of Neonatology, 29988Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.,Department of Paediatrics, 75452Aarupadai Veedu Medical College, Puducherry, India
| |
Collapse
|
21
|
Batey N, Henry C, Garg S, Wagner M, Malhotra A, Valstar M, Smith T, Sharkey D. The newborn delivery room of tomorrow: emerging and future technologies. Pediatr Res 2022:10.1038/s41390-022-01988-y. [PMID: 35241791 DOI: 10.1038/s41390-022-01988-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/10/2022] [Accepted: 02/01/2022] [Indexed: 11/08/2022]
Abstract
Advances in neonatal care have resulted in improved outcomes for high-risk newborns with technologies playing a significant part although many were developed for the neonatal intensive care unit. The care provided in the delivery room (DR) during the first few minutes of life can impact short- and long-term neonatal outcomes. Increasingly, technologies have a critical role to play in the DR particularly with monitoring and information provision. However, the DR is a unique environment and has major challenges around the period of foetal to neonatal transition that need to be overcome when developing new technologies. This review focuses on current DR technologies as well as those just emerging and further over the horizon. We identify what key opinion leaders in DR care think of current technologies, what the important DR measures are to them, and which technologies might be useful in the future. We link these with key technologies including respiratory function monitors, electoral impedance tomography, videolaryngoscopy, augmented reality, video recording, eye tracking, artificial intelligence, and contactless monitoring. Encouraging funders and industry to address the unique technological challenges of newborn care in the DR will allow the continued improvement of outcomes of high-risk infants from the moment of birth. IMPACT: Technological advances for newborn delivery room care require consideration of the unique environment, the variable patient characteristics, and disease states, as well as human factor challenges. Neonatology as a speciality has embraced technology, allowing its rapid progression and improved outcomes for infants, although innovation in the delivery room often lags behind that in the intensive care unit. Investing in new and emerging technologies can support healthcare providers when optimising care and could improve training, safety, and neonatal outcomes.
Collapse
Affiliation(s)
- Natalie Batey
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Caroline Henry
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalabh Garg
- Department of Neonatal Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital and Department of Paediatrics, Monash University, Melbourne, Australia
| | - Michel Valstar
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Thomas Smith
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK.
| |
Collapse
|
22
|
Zeballos Sarrato G, Ávila-Álvarez A, Escrig Fernández R, Izquierdo Renau M, Ruiz Campillo CW, Gómez Robles C, Iriondo Sanz M. Spanish guide for neonatal stabilization and resuscitation 2021: Analysis, adaptation and consensus on international recommendations. An Pediatr (Barc) 2022; 96:145.e1-145.e9. [PMID: 35216951 DOI: 10.1016/j.anpede.2021.06.011] [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: 05/18/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022] Open
Abstract
After the publication of the recommendations, agreed by all the scientific societies through the ILCOR, at the end of 2020, the GRN-SENeo began a process of analysis and review of the main changes since the last guidelines, to which a specific consensus positioning on controversial issues, trying to avoid ambiguities and trying to adapt the evidence to our environment. This text summarizes the main conclusions of this work and reflects the positioning of that group.
Collapse
Affiliation(s)
| | - Alejandro Ávila-Álvarez
- Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario, A Coruña (CHUAC), Sergas, A Coruña, Spain
| | | | - Montserrat Izquierdo Renau
- Servicio de Neonatología, Sant Joan de Déu, BCNatal, Hospital Sant Joan de Déu-Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| | | | - Celia Gómez Robles
- Servicio de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Martín Iriondo Sanz
- Servicio de Neonatología, Sant Joan de Déu, BCNatal, Hospital Sant Joan de Déu-Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| |
Collapse
|
23
|
Chavez L, Meguro J, Chen S, de Paiva VN, Zambrano R, Eterno JM, Kumar R, Duncan MR, Benny M, Young KC, Dietrich WD, Brambilla R, Wu S, Schmidt AF. Circulating extracellular vesicles activate the pyroptosis pathway in the brain following ventilation-induced lung injury. J Neuroinflammation 2021; 18:310. [PMID: 34965880 PMCID: PMC8717639 DOI: 10.1186/s12974-021-02364-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/17/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Mechanical ventilation of preterm newborns causes lung injury and is associated with poor neurodevelopmental outcomes. However, the mechanistic links between ventilation-induced lung injury (VILI) and brain injury is not well defined. Since circulating extracellular vesicles (EVs) are known to link distant organs by transferring their cargos, we hypothesized that EVs mediate inflammatory brain injury associated with VILI. METHODS Neonatal rats were mechanically ventilated with low (10 mL/kg) or high (25 mL/kg) tidal volume for 1 h on post-natal day 7 followed by recovery for 2 weeks. Exosomes were isolated from the plasma of these rats and adoptively transferred into normal newborn rats. We assessed the effect of mechanical ventilation or exosome transfer on brain inflammation and activation of the pyroptosis pathway by western blot and histology. RESULTS Injurious mechanical ventilation induced similar markers of inflammation and pyroptosis, such as increased IL-1β and activated caspase-1/gasdermin D (GSDMD) in both lung and brain, in addition to inducing microglial activation and cell death in the brain. Isolated EVs were enriched for the exosomal markers CD9 and CD81, suggesting enrichment for exosomes. EVs isolated from neonatal rats with VILI had increased caspase-1 but not GSDMD. Adoptive transfer of these EVs led to neuroinflammation with microglial activation and activation of caspase-1 and GSDMD in the brain similar to that observed in neonatal rats that were mechanically ventilated. CONCLUSIONS These findings suggest that circulating EVs can contribute to the brain injury and poor neurodevelopmental outcomes in preterm infants with VILI through activation of GSDMD.
Collapse
Affiliation(s)
- Laura Chavez
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Julia Meguro
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Shaoyi Chen
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Vanessa Nunes de Paiva
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Ronald Zambrano
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Julia M Eterno
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Rahul Kumar
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Matthew R Duncan
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Merline Benny
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Karen C Young
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - W Dalton Dietrich
- The Miami Project To Cure Paralysis, Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roberta Brambilla
- The Miami Project To Cure Paralysis, Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Shu Wu
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Augusto F Schmidt
- Department of Pediatrics, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA.
| |
Collapse
|
24
|
Tidal volumes and pressures delivered by the NeoPuff T-piece resuscitator during resuscitation of term newborns. Resuscitation 2021; 170:222-229. [PMID: 34915085 DOI: 10.1016/j.resuscitation.2021.12.006] [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] [Received: 10/22/2021] [Revised: 12/02/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022]
Abstract
AIM T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator. METHOD Observational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1-20) and a late (inflation 21-100) phase. RESULTS Of the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28-31) and 30 (27-31) mbar, and tidal volume was 4.5 (1.6-7.8) and 5.7 (2.2-9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes. CONCLUSION There was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30-40 per minute are associated with the highest delivered tidal volumes.
Collapse
|
25
|
Biswas A, Ho SKY, Yip WY, Kader KBA, Kong JY, Ee KTT, Baral VR, Chinnadurai A, Quek BH, Yeo CL. Singapore Neonatal Resuscitation Guidelines 2021. Singapore Med J 2021; 62:404-414. [PMID: 35001116 PMCID: PMC8804489 DOI: 10.11622/smedj.2021110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
Neonatal resuscitation is a coordinated, team-based series of timed sequential steps that focuses on a transitional physiology to improve perinatal and neonatal outcomes. The practice of neonatal resuscitation has evolved over time and continues to be shaped by emerging evidence as well as key opinions. We present the revised Neonatal Resuscitation Guidelines for Singapore 2021. The recommendations from the International Liaison Committee on Resuscitation Neonatal Task Force Consensus on Science and Treatment Recommendations (2020) and guidelines from the American Heart Association and European Resuscitation Council were compared with existing guidelines. The recommendations of the Neonatal Subgroup of the Singapore Resuscitation and First Aid Council were derived after the work group discussed and appraised the current available evidence and their applicability to local clinical practice.
Collapse
Affiliation(s)
- Agnihotri Biswas
- Department of Neonatology, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
| | - Selina Kah Ying Ho
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Wai Yan Yip
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Khadijah Binti Abdul Kader
- Department of Neonatology, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Juin Yee Kong
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Kenny Teong Tai Ee
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
- Kinder Clinic Pte Ltd, Singapore
| | - Vijayendra Ranjan Baral
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Amutha Chinnadurai
- Department of Neonatology, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bin Huey Quek
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Cheo Lian Yeo
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| |
Collapse
|
26
|
Zeballos Sarrato G, Avila-Alvarez A, Escrig Fernández R, Izquierdo Renau M, Ruiz Campillo CW, Gómez Robles C, Iriondo Sanz M. [Spanish guide for neonatal stabilization and resuscitation 2021: Analysis, adaptation and consensus on international recommendations]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00213-7. [PMID: 34304987 DOI: 10.1016/j.anpedi.2021.06.003] [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] [Received: 05/18/2021] [Revised: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 11/24/2022] Open
Abstract
After the publication of the recommendations, agreed by all the scientific societies through the ILCOR, at the end of 2020, the GRN-SENeo began a process of analysis and review of the main changes since the last guidelines, to which a specific consensus positioning on controversial issues, trying to avoid ambiguities and trying to adapt the evidence to our environment. This text summarizes the main conclusions of this work and reflects the positioning of that group.
Collapse
Affiliation(s)
| | - Alejandro Avila-Alvarez
- Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario, A Coruña (CHUAC), Sergas, A Coruña, España
| | | | - Montserrat Izquierdo Renau
- Servicio de Neonatología, Sant Joan de Déu, BCNatal, Hospital Sant Joan de Déu-Hospital Clínic, Universidad de Barcelona, Barcelona, España
| | | | - Celia Gómez Robles
- Servicio de Neonatología, Hospital Regional Universitario de Málaga, Málaga, España
| | - Martín Iriondo Sanz
- Servicio de Neonatología, Sant Joan de Déu, BCNatal, Hospital Sant Joan de Déu-Hospital Clínic, Universidad de Barcelona, Barcelona, España
| |
Collapse
|
27
|
A multi-centre randomised controlled trial of respiratory function monitoring during stabilisation of very preterm infants at birth. Resuscitation 2021; 167:317-325. [PMID: 34302924 DOI: 10.1016/j.resuscitation.2021.07.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 11/21/2022]
Abstract
AIM To determine whether the use of a respiratory function monitor (RFM) during PPV of extremely preterm infants at birth, compared with no RFM, leads to an increase in percentage of inflations with an expiratory tidal volume (Vte) within a predefined target range. METHODS Unmasked, randomised clinical trial conducted October 2013 - May 2019 in 7 neonatal intensive care units in 6 countries. Very preterm infants (24-27 weeks of gestation) receiving PPV at birth were randomised to have a RFM screen visible or not. The primary outcome was the median proportion of inflations during manual PPV (face mask or intubated) within the target range (Vte 4-8 mL/kg). There were 42 other prespecified monitor measurements and clinical outcomes. RESULTS Among 288 infants randomised (median (IQR) gestational age 26+2 (25+3-27+1) weeks), a total number of 51,352 inflations were analysed. The median (IQR) percentage of inflations within the target range in the RFM visible group was 30.0 (18.0-42.2)% vs 30.2 (14.8-43.1)% in the RFM non-visible group (p = 0.721). There were no differences in other respiratory function measurements, oxygen saturation, heart rate or FiO2. There were no differences in clinical outcomes, except for the incidence of intraventricular haemorrhage (all grades) and/or cystic periventricular leukomalacia (visible RFM: 26.7% vs non-visible RFM: 39.0%; RR 0.71 (0.68-0.97); p = 0.028). CONCLUSION In very preterm infants receiving PPV at birth, the use of a RFM, compared to no RFM as guidance for tidal volume delivery, did not increase the percentage of inflations in a predefined target range. TRIAL REGISTRATION Dutch Trial Register NTR4104, clinicaltrials.gov NCT03256578.
Collapse
|
28
|
Badawi N, Mcintyre S, Hunt RW. Perinatal care with a view to preventing cerebral palsy. Dev Med Child Neurol 2021; 63:156-161. [PMID: 33251607 PMCID: PMC7839537 DOI: 10.1111/dmcn.14754] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 01/02/2023]
Abstract
Birth prevalence of cerebral palsy (CP) is declining in high-income countries, to as low as 1.4 per 1000 live births in the most recent international reports. This represents a 35% reduction in birth prevalence over a 15-year period. This reduction is underpinned by a heightened focus of attention towards all aspects of CP, including: increased awareness, better data collection, development of national networks and registries, an explosion of research in basic science, perinatal care, neonatal neurology, public health, early detection, and targeted early intervention. Quick uptake of evidence into practice has ensued and overall improvements in clinical care occurred concurrently. It is anticipated that with continued partnerships with families, ongoing research driving further clinical improvement and vice versa, birth prevalence and severity of CP will further decline and the focus will shift to prevention in low- and middle-income countries. WHAT THIS PAPER ADDS: Research in the field of perinatal care and cerebral palsy (CP) prevention has increased significantly. In high-income countries, increased awareness of CP and scientific advances have improved clinical care. Population-based registers have limitations but remain the best mechanism to quantify birth prevalence of CP and accurately track trends. There have been recent reductions in the birth prevalence of CP.
Collapse
Affiliation(s)
- Nadia Badawi
- Grace Centre for Newborn CareChildren's Hospital at Westmead Sydney Children's Hospital NetworkSydneyNSWAustralia,Cerebral Palsy Alliance Research InstituteSpecialty of Child & Adolescent HealthSydney Medical SchoolFaculty of Medicine & HealthThe University of SydneySydneyNSWAustralia
| | - Sarah Mcintyre
- Cerebral Palsy Alliance Research InstituteSpecialty of Child & Adolescent HealthSydney Medical SchoolFaculty of Medicine & HealthThe University of SydneySydneyNSWAustralia
| | - Rod W Hunt
- Department of PaediatricsMonash UniversityMelbourneVICAustralia,Neonatal ResearchClinical SciencesMurdoch Children's Research InstituteMelbourneVICAustralia,Monash NewbornMonash HealthMelbourneVICAustralia
| |
Collapse
|
29
|
Hinder MK, Drevhammar T, Donaldsson S, Boustred M, Crott M, Tracy MB. T-piece resuscitators: can they provide safe ventilation in a low compliant newborn lung? Arch Dis Child Fetal Neonatal Ed 2021; 106:25-30. [PMID: 32546543 DOI: 10.1136/archdischild-2019-318673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/03/2020] [Accepted: 05/08/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND T-piece resuscitators (TPRs) are used for primary newborn resuscitation in birthing and emergency rooms worldwide. A recent study has shown spikes in peak inflation pressure (PIP) over set values with two brands of TPRs inbuilt into infant warmer/resuscitation platforms. We aimed to compare delivered ventilation between two TPR drivers with inflation pressure spikes to a standard handheld TPR in a low test lung compliance (Crs), leak-free bench test model. METHODS A single operator provided positive pressure ventilation to a low compliance test lung model (Crs 0.2-1 mL/cmH2O) at set PIP of 15, 25, 35 and 40 cmH2O. Two TPR devices with known spikes (Draeger Resuscitaire, GE Panda) were compared with handheld Neopuff (NP). Recommended settings for positive end-expiratory pressure (5 cmH2O), inflation rate of 60/min and gas flow rate 10 L/min were used. RESULTS 2293 inflations were analysed. Draeger and GE TPR drivers delivered higher mean PIP (Panda 18.9-49.5 cmH2O; Draeger 21.2-49.2 cmH2O and NP 14.8-39.9 cmH2O) compared with set PIP and tidal volumes (TVs) compared with the NP (Panda 2.9-7.8 mL; Draeger 3.8-8.1 mL; compared with NP 2.2-6.0 mL), outside the prespecified acceptable range (±10% of set PIP and ±10% TV compared with NP). CONCLUSION The observed spike in PIP over set values with Draeger and GE Panda systems resulted in significantly higher delivered volumes compared with the NP with identical settings. Manufacturers need to address these differences. The effect on patient outcomes is unknown.
Collapse
Affiliation(s)
- Murray Kenneth Hinder
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia .,Department of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Thomas Drevhammar
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Snorri Donaldsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Matthew Boustred
- School of Biomedical Engineering, The University of Sydney, Sydney, New South Wales, Australia
| | - Matthew Crott
- School of Biomedical Engineering, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Brian Tracy
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
30
|
Tidal volume measurements in the delivery room in preterm infants requiring positive pressure ventilation via endotracheal tube-feasibility study. J Perinatol 2021; 41:1930-1935. [PMID: 34112962 PMCID: PMC8191447 DOI: 10.1038/s41372-021-01113-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/05/2021] [Accepted: 05/18/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Current delivery room (DR) resuscitation utilizes pressure-limited devices without tidal volume (TV) measurements. Clinicians use chest expansion as a surrogate, which is a poor indicator of TV. TV in early life can be highly variable due to rapidly changing lung compliance. Our objectives were to assess feasibility of measuring TV in DR, and to report the generated TV in intubated patients. STUDY DESIGN Prospective, observational, feasibility study in infants <32 weeks GA and intubated in DR. TV was measured using a respiratory function monitor. RESULT Ten infants with mean GA 23.9(±1.5) weeks and mean BW 618.5(±155) gram were included. Total of 178 min (mean 17.8 min/patient) with 8175 individual breaths (mean 817.5 breaths/patient) were analyzed. Goal TV of 4-6 ml/kg was provided 23.5% of times with high TV (>6 ml/kg) provided 47.7% of times. CONCLUSION TV measurement in DR is feasible. It is associated with high intra and inter-patient variability.
Collapse
|
31
|
Yang KC, Te Pas AB, Weinberg DD, Foglia EE. Corrective steps to enhance ventilation in the delivery room. Arch Dis Child Fetal Neonatal Ed 2020; 105:605-608. [PMID: 32152191 DOI: 10.1136/archdischild-2019-318579] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The clinical impact of ventilation corrective steps for delivery room positive pressure ventilation (PPV) is not well studied. We aimed to characterise the performance and effect of ventilation corrective steps (MRSOPA (Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase and Alternative airway)) during delivery room resuscitation of preterm infants. DESIGN Prospective observational study of delivery room PPV using video and respiratory function monitor recordings. SETTING Tertiary academic delivery hospital. PATIENTS Preterm infants <32 weeks gestation. MAIN OUTCOME MEASURE Mean exhaled tidal volume (Vte) of PPV inflations before and after MRSOPA interventions, categorised as inadequate (<4 mL/kg); appropriate (4-8 mL/kg), or excessive (>8 mL/kg). Secondary outcomes were leak (>30%) and obstruction (Vte <1 mL/kg), and infant heart rate. RESULTS There were 41 corrective interventions in 30 infants, with a median duration of 15 (IQR 7-29) s. The most frequent intervention was a combination of Mask/Reposition and Suction/Open. Mean Vte was inadequate before 16/41 interventions and became adequate following 6/16. Mean Vte became excessive after 6/41 interventions. Mask leak, present before 13/41 interventions, was unchanged after 4 and resolved after 9. Obstruction was present before five interventions and was subsequently resolved only once. MRSOPA interventions introduced leak in two cases and led to obstruction in one case. The heart rate was <100 beats per minute before 31 interventions and rose to >100 beats per minute after 14/31 of these. CONCLUSIONS Ventilation correction interventions improve tidal volume delivery in some cases, but lead to ineffective or excessive tidal volumes in others. Mask leak and obstruction can be induced by MRSOPA manoeuvres.
Collapse
Affiliation(s)
- Kesi C Yang
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arjan B Te Pas
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Danielle D Weinberg
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
32
|
Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S524-S550. [DOI: 10.1161/cir.0000000000000902] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
33
|
Inocencio IM, Tran NT, Nakamura S, Khor SJ, Wiersma M, Stoecker K, Polglase GR, Pearson JT, Wong FY. Increased peak end-expiratory pressure in ventilated preterm lambs changes cerebral microvascular perfusion: direct synchrotron microangiography assessment. J Appl Physiol (1985) 2020; 129:1075-1084. [PMID: 32909920 DOI: 10.1152/japplphysiol.00652.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Positive end-expiratory pressure (PEEP) improves oxygenation in mechanically ventilated preterm neonates by preventing lung collapse. However, high PEEP may alter cerebral blood flow secondarily to the increased intrathoracic pressure, predisposing to brain injury. The precise effects of high PEEP on cerebral hemodynamics in the preterm brain are unknown. We aimed to assess the effect of PEEP on microvessels in the preterm brain by using synchrotron radiation (SR) microangiography, which enables in vivo real-time high-resolution imaging of the cerebral vasculature. Preterm lambs (0.8 gestation, n = 4) were delivered via caesarean section, anesthetized, and ventilated. SR microangiography of the right cerebral hemisphere was performed with iodine contrast administered into the right carotid artery during PEEP ventilation of 5 and 10 cmH2O. Carotid blood flow was measured using an ultrasonic flow probe placed around the left carotid artery. An increase of PEEP from 5 to 10 cmH2O increased the diameter of small cerebral vessels (<150 µm) but decreased the diameter of larger cerebral vessels (>500 µm) in all four lambs. Additionally, the higher PEEP increased the cerebral contrast transit time in three of the four lambs. Carotid blood flow increased in two lambs, which also had increased carbon dioxide levels during PEEP 10. Our results suggest that PEEP of 10 cmH2O alters the preterm cerebral hemodynamics, with prolonged cerebral blood flow transit and engorgement of small cerebral microvessels likely due to the increased intrathoracic pressure. These microvascular changes are generally not reflected in global assessment of cerebral blood flow or oxygenation.NEW & NOTEWORTHY An increase of positive end-expiratory pressure (PEEP) from 5 to 10 cmH2O increased the diameter of small cerebral vessels (<150 µm) but decreased the diameter of larger cerebral vessels (>500 µm). This suggests increased intrathoracic pressure due to high PEEP can drive microvessel engorgement in the preterm brain, which may play a role in cerebrovascular injury.
Collapse
Affiliation(s)
- Ishmael Miguel Inocencio
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Nhi Thao Tran
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Shinji Nakamura
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Song J Khor
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Manon Wiersma
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Katja Stoecker
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - James T Pearson
- Department of Cardiac Physiology, National Cerebral and Cardiovascular Centre, Osaka, Japan.,Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Flora Y Wong
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, VIC, Australia
| |
Collapse
|
34
|
Weydig H, Ali N, Kakkilaya V. Noninvasive Ventilation in the Delivery Room for the Preterm Infant. Neoreviews 2020; 20:e489-e499. [PMID: 31477597 DOI: 10.1542/neo.20-9-e489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A decade ago, preterm infants were prophylactically intubated and mechanically ventilated starting in the delivery room; however, now the shift is toward maintaining even the smallest of neonates on noninvasive respiratory support. The resuscitation of very low gestational age neonates continues to push the boundaries of neonatal care, as the events that transpire during the golden minutes right after birth prove ever more important for determining long-term neurodevelopmental outcomes. Continuous positive airway pressure (CPAP) remains the most important mode of noninvasive respiratory support for the preterm infant to establish and maintain functional residual capacity and decrease ventilation/perfusion mismatch. However, the majority of extremely low gestational age infants require face mask positive pressure ventilation during initial stabilization before receiving CPAP. Effectiveness of face mask positive pressure ventilation depends on the ability to detect and overcome mask leak and airway obstruction. In this review, the current evidence on devices and techniques of noninvasive ventilation in the delivery room are discussed.
Collapse
Affiliation(s)
- Heather Weydig
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Noorjahan Ali
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
35
|
Chan KYY, Miller SL, Schmölzer GM, Stojanovska V, Polglase GR. Respiratory Support of the Preterm Neonate: Lessons About Ventilation-Induced Brain Injury From Large Animal Models. Front Neurol 2020; 11:862. [PMID: 32922358 PMCID: PMC7456830 DOI: 10.3389/fneur.2020.00862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
Many preterm neonates require mechanical ventilation which increases the risk of cerebral inflammation and white matter injury in the immature brain. In this review, we discuss the links between ventilation and brain injury with a focus on the immediate period after birth, incorporating respiratory support in the delivery room and subsequent mechanical ventilation in the neonatal intensive care unit. This review collates insight from large animal models in which acute injurious ventilation and prolonged periods of ventilation have been used to create clinically relevant brain injury patterns. These models are valuable resources in investigating the pathophysiology of ventilation-induced brain injury and have important translational implications. We discuss the challenges of reconciling lung and brain maturation in commonly used large animal models. A comprehensive understanding of ventilation-induced brain injury is necessary to guide the way we care for preterm neonates, with the goal to improve their neurodevelopmental outcomes.
Collapse
Affiliation(s)
- Kyra Y. Y. Chan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Georg M. Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| |
Collapse
|
36
|
Chiu HY, Chu SM, Lin HY, Tsai ML, Chen YT, Lin HC. Evidence base multi-discipline critical strategies toward better tomorrow for very preterm infants. Pediatr Neonatol 2020; 61:371-377. [PMID: 32201157 DOI: 10.1016/j.pedneo.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/30/2019] [Accepted: 01/21/2020] [Indexed: 12/15/2022] Open
Abstract
Despite advances in neonatal intensive care in the recent decade, a large number of very preterm infants (VPIs) remain at risk for significant neurodevelopmental impairment (NDI). Given that there are many interventions need to be implemented during the critical perinatal period so that complications of these vulnerable VPIs could be minimized, it is urgent to develop multi-discipline strategies based on evidence to be carried out. The objective of this new term evidence-based perinatal critical strategies (EBPCS), is to provide beneficial intervention towards better neurodevelopmental outcomes, specifically for preterm infants below 28 weeks gestational age. EBPCS is defined as the management of the VPIs during the perinatal period which would include antenatal counseling with team briefing and share decision making, treat the chorioamnionitis, antenatal MgS04, antenatal steroid, delayed cord clamping/milking, neonatal resuscitation team preparation, prevention of hypothermia, immediate respiratory support with continuous positive airway pressure at delivery room, less invasive surfactant administration, early surfactant with budesonide therapy, support of cardiovascular system, early initiate of probiotics administration, early caffeine, early parenteral and enteral nutrition, promptly initiating antibiotics. These critical strategies will be discussed detail in the text; nonetheless, standardized protocols, technical skills and repeated training are the cornerstones of successful of EBPCS. Further experience from different NICU is needed to prove whether these very complicate and comprehensive perinatal critical strategies could translate into daily practice to mitigate the incidence of NDI in high-risk VPIs.
Collapse
Affiliation(s)
- Hsiao-Yu Chiu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Hsiang-Yu Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Ming-Luen Tsai
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Yin-Ting Chen
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chih Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Asia University Hospital, Asia University, Taichung, Taiwan.
| |
Collapse
|
37
|
Brain inflammation and injury at 48 h is not altered by human amnion epithelial cells in ventilated preterm lambs. Pediatr Res 2020; 88:27-37. [PMID: 32120374 DOI: 10.1038/s41390-020-0815-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/18/2020] [Accepted: 02/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mechanical ventilation of preterm neonates is associated with neuroinflammation and an increased risk of adverse neurological outcomes. Human amnion epithelial cells (hAECs) have anti-inflammatory and regenerative properties. We aimed to determine if intravenous administration of hAECs to preterm lambs would reduce neuroinflammation and injury at 2 days of age. METHODS Preterm lambs were delivered by cesarean section at 128-130 days' gestation (term is ~147 days) and either ventilated for 48 h or humanely killed at birth. Lambs received 3 mL surfactant (Curosurf) via endotracheal tube prior to delivery (either with or without 90 × 106 hAECs) and 3 mL intravenous phosphate-buffered saline (with or without 90 × 106 hAECs, consistent with intratracheal treatment) after birth. RESULTS Ventilation increased microglial activation, total oligodendrocyte cell number, cell proliferation and blood-brain barrier permeability (P < 0.05, PBS + ventilation and hAEC + ventilation vs. control), but did not affect numbers of immature and mature oligodendrocytes. Ventilation reduced astrocyte and neuron survival (P < 0.05, PBS + ventilation and hAEC + ventilation vs. control). hAEC administration did not alter markers of neuroinflammation or injury within the white or gray matter. CONCLUSIONS Mechanical ventilation for 48 h upregulated markers of neuroinflammation and injury in preterm lambs. Administration of hAECs did not affect markers of neuroinflammation or injury. IMPACT Mechanical ventilation of preterm lambs for 48 h, in a manner consistent with contemporary neonatal intensive care, causes neuroinflammation, neuronal loss and pathological changes in oligodendrocyte and astrocyte survival consistent with evolving neonatal brain injury.Intravenous administration of hAECs immediately after birth did not affect neonatal cardiorespiratory function and markers of neuroinflammation or injury.Reassuringly, our findings in a translational large animal model demonstrate that intravenous hAEC administration to the preterm neonate is safe.Considering that hAECs are being used in phase 1 trials for the treatment of BPD in preterm infants, with future trials planned for neonatal neuroprotection, we believe these observations are highly relevant.
Collapse
|
38
|
Shim GH, Kim SY, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM. Effects of sustained inflation pressure during neonatal cardiopulmonary resuscitation of asphyxiated piglets. PLoS One 2020; 15:e0228693. [PMID: 32574159 PMCID: PMC7310834 DOI: 10.1371/journal.pone.0228693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/05/2020] [Indexed: 11/18/2022] Open
Abstract
Background Sustained inflation (SI) during chest compression (CC = CC+SI) has been recently shown as an alternative method during cardiopulmonary resuscitation in neonates. However, the optimal peak inflation pressure (PIP) of SI during CC+SI to improve ROSC and hemodynamic recovery is unknown. Objective To examine if different PIPs of SI during CC+SI will improve ROSC and hemodynamic recovery in severely asphyxiated piglets. Methods Twenty-nine newborn piglets (1–3 days old) were anesthetized, intubated, instrumented and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into four groups: CC+SI with a PIP of 10 cmH2O (CC+SI_PIP_10, n = 8), a PIP of 20 cmH2O (CC+SI_PIP_20, n = 8), a PIP of 30 cmH2O (CC+SI_PIP_30, n = 8), and a sham-operated control group (n = 5). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. Results Baseline parameters were similar between all groups. There was no difference in asphyxiation (duration and degree) between intervention groups. PIP correlated positively with tidal volume (VT) and inversely with exhaled CO2 during cardiopulmonary resuscitation. Time to ROSC and rate of ROSC were similar between piglets resuscitated with CC+SI_PIP_10, CC+SI_PIP_20, and CC+SI_PIP_30 cmH2O: median (IQR) 75 (63–193) sec, 94 (78–210) sec, and 85 (70–90) sec; 5/8 (63%), 7/8 (88%), and 3/8 (38%) (p = 0.56 and p = 0.12, respectively). All piglets that achieved ROSC survived to four hours post-resuscitation. Piglets resuscitated with CC+SI_PIP_30 cmH2O exhibited increased concentrations of pro-inflammatory cytokines interleukin-1β and tumour necrosis factor-α in the frontoparietal cerebral cortex (both p<0.05 vs. sham-operated controls). Conclusion In asphyxiated term newborn piglets resuscitated by CC+SI, the use of different PIPs resulted in similar time to ROSC, but PIP at 30 cmH2O showed a larger VT delivery, lower exhaled CO2 and increased tissue inflammatory markers in the brain.
Collapse
Affiliation(s)
- Gyu-Hong Shim
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Seung Yeun Kim
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Eulji University Hospital, Daejeon, Korea
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| |
Collapse
|
39
|
Sawyer T, Motz P, Schooley N, Umoren R. Positive pressure ventilation coaching during neonatal bag-mask ventilation: A simulation-based pilot study. J Neonatal Perinatal Med 2020; 12:243-248. [PMID: 30909252 DOI: 10.3233/npm-1618119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Positive pressure ventilation (PPV) is the most important procedure during neonatal resuscitation. Providing effective PPV seems easy. However, performing the procedure correctly is extremely challenging. Airway obstruction and face mask large leaks are common. It is estimated that two-thirds of continued neonatal respiratory depression after the time of birth is caused by ineffective or improperly provided PPV. Finding methods to improve PPV performance are critically needed. Performance coaching is a simple and easy method of improving performing in procedural skills, and has been used previously to optimize compression technique. We performed the simulation-based pilot study to evaluate the impact of PPV coaching during neonatal bag-mask ventilation. METHODS Randomized cross-over study of nurses performing PPV on a SMART Newborn Resuscitation Training System with, and without, coaching. The PPV coach provided real-time feedback on chest rise, mask hold, and ventilation rate. The SMART system captured data on peak inspiratory pressure (PIP), tidal volume (Vt), mask leak, and ventilation rate. Data were analyzed by a blinded reviewer. RESULTS PPV coaching resulted in more appropriate PIPs (34 cmH2O, IQR 32-38 vs. 36 cmH2O, IQR 28-37; P < 0.001), lower Vt (4.7 ml/kg, IQR 4-8 vs. 5.5 ml/kg, IQR 4-13; P < 0.001), and less mask leak (39% leak, IQR 21-70 vs. 45%, IQR 22-98; P = 0.005). There was no difference in respiratory rate (P = 0.93). CONCLUSIONS Coaching improved PPV performance in this simulation-based pilot study. Further research on PPV coaching during neonatal resuscitation is warranted.
Collapse
Affiliation(s)
- T Sawyer
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - P Motz
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - N Schooley
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - R Umoren
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| |
Collapse
|
40
|
Hillman NH, Kothe TB, Schmidt AF, Kemp MW, Royse E, Fee E, Salomone F, Clarke MW, Musk GC, Jobe AH. Surfactant plus budesonide decreases lung and systemic responses to injurious ventilation in preterm sheep. Am J Physiol Lung Cell Mol Physiol 2020; 318:L41-L48. [PMID: 31617728 PMCID: PMC6985873 DOI: 10.1152/ajplung.00203.2019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/09/2019] [Accepted: 09/30/2019] [Indexed: 11/22/2022] Open
Abstract
Mechanical ventilation from birth with normal tidal volumes (VT) causes lung injury and systemic responses in preterm sheep. The addition of budesonide to surfactant therapy decreases these injury markers. Budesonide and surfactant will decrease the injury from injurious VT ventilation in preterm sheep. Lambs at 126 ± 1 day gestational age were ventilated from birth with either: 1) Normal VT [surfactant 200 mg/kg before ventilation, positive end expiratory pressure (PEEP) 5 cmH2O, VT 8 mL/kg] or 2) Injury VT (high pressure, 100% oxygen, no PEEP) for 15 min, then further randomized to surfactant + saline or surfactant + 0.25 mg/kg budesonide with Normal VT for 6 h. Lung function and lung, liver, and brain tissues were evaluated for indicators of injury. Injury VT + saline caused significant injury and systemic responses, and Injury VT + budesonide improved lung physiology. Budesonide decreased lung inflammation and decreased pro-inflammatory cytokine mRNA in the lung, liver, and brain to levels similar to Normal VT + saline. Budesonide was present in plasma within 15 min of treatment in both ventilation groups, and less than 5% of the budesonide remained in the lung at 6 h. mRNA sequencing of liver and periventricular white matter demonstrated multiple pathways altered by both Injury VT and budesonide and the combination exposure. In lambs receiving Injury VT, the addition of budesonide to surfactant improved lung physiology and decreased pro-inflammatory cytokine responses in the lung, liver, and brain to levels similar to lambs receiving Normal VT.
Collapse
Affiliation(s)
- Noah H Hillman
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, Missouri
| | - T Brett Kothe
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, Missouri
| | - Augusto F Schmidt
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Matthew W Kemp
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
| | - Emily Royse
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, Missouri
| | - Erin Fee
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - Michael W Clarke
- Metabolomics Australia, Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, Western Australia, Australia
| | - Gabrielle C Musk
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
- Animal Care Services, University of Western Australia, Perth, Western Australia, Australia
| | - Alan H Jobe
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
41
|
End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage. Eur J Pediatr 2020; 179:555-559. [PMID: 31848749 PMCID: PMC7080666 DOI: 10.1007/s00431-019-03543-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/18/2022]
Abstract
Abnormal levels of end-tidal carbon dioxide (EtCO2) during resuscitation in the delivery suite are associated with intraventricular haemorrhage (IVH) development. Our aim was to determine whether carbon dioxide (CO2) levels in the first 3 days after birth reflected abnormal EtCO2 levels in the delivery suite, and hence, a prolonged rather than an early insult resulted in IVH. In addition, we determined if greater EtCO2level fluctuations during resuscitation occurred in infants who developed IVH. EtCO2 levels during delivery suite resuscitation and CO2 levels on the neonatal unit were evaluated in 58 infants (median gestational age 27.3 weeks). Delta EtCO2 was the difference between the highest and lowest level of EtCO2. Thirteen infants developed a grade 3-4 IVH (severe group). There were no significant differences in CO2 levels between those who did and did not develop an IVH (or severe IVH) on the NICU. The delta EtCO2 during resuscitation differed between infants with any IVH (6.2 (5.4-7.5) kPa) or no IVH (3.8 (2.7-4.3) kPA) (p < 0.001) after adjusting for differences in gestational age. Delta EtCO2 levels gave an area under the ROC curve of 0.940 for prediction of IVH.Conclusion: The results emphasize the importance of monitoring EtCO2 levels in the delivery suite.What is Known:• Abnormal levels of carbon dioxide (CO2) in the first few days after birth and abnormal end-tidal CO2levels (EtCO2) levels during resuscitation are associated in preterm infants with the risk of developing intraventricular haemorrhage (IVH).What is New:• There were no significant differences in NICU CO2levels between those who developed an IVH or no IVH.• There was a poor correlation between delivery suite ETCO2levels and NICU CO2levels.• Large fluctuations in EtCO2during resuscitation in the delivery suite were highly predictive of IVH development in preterm infants.
Collapse
|
42
|
PRECONDITIONS FOR EARLY AND LATE INTRAVENTRICULAR HEMORRHAGES IN PRETERM VERY LOW BIRTH WEIGHT INFANTS. WORLD OF MEDICINE AND BIOLOGY 2020. [DOI: 10.26724/2079-8334-2020-3-73-47-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
43
|
Brouwer E, Knol R, Vernooij ASN, van den Akker T, Vlasman PE, Klumper FJCM, DeKoninck P, Polglase GR, Hooper SB, te Pas AB. Physiological-based cord clamping in preterm infants using a new purpose-built resuscitation table: a feasibility study. Arch Dis Child Fetal Neonatal Ed 2019; 104:F396-F402. [PMID: 30282674 PMCID: PMC6764254 DOI: 10.1136/archdischild-2018-315483] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Physiological-based cord clamping (PBCC) led to a more stable cardiovascular adaptation and better oxygenation in preterm lambs, but in preterm infants, this approach has been challenging. Our aim was to assess the feasibility of PBCC, including patterns of oxygen saturation (SpO2) and heart rate (HR) during stabilisation in preterm infants using a new purpose-built resuscitation table. DESIGN Observational study. SETTING Tertiary referral centre, Leiden University Medical Centre, The Netherlands. PATIENTS Infants born below 35 weeks' gestational age. INTERVENTIONS Infants were stabilised on a new purpose-built resuscitation table (Concord), provided with standard equipment needed for stabilisation. Cord clamping was performed when the infant was stable (HR >100 bpm, spontaneous breathing on continuous positive airway pressure with tidal volumes >4 mL/kg, SpO2 ≥25th percentile and fraction of inspired oxygen (FiO2) <0.4). RESULTS Thirty-seven preterm infants were included; mean (SD) gestational age of 30.9 (2.4) weeks, birth weight 1580 (519) g. PBCC was successful in 33 infants (89.2%) and resulted in median (IQR) cord clamping time of 4:23 (3:00-5:11) min after birth. There were no maternal or neonatal adverse events. In 26/37 infants, measurements were adequate for analysis. HR was 113 (81-143) and 144 (129-155) bpm at 1 min and 5 min after birth. SpO2 levels were 58%(49%-60%) and 91%(80%-96%)%), while median FiO2 given was 0.30 (0.30-0.31) and 0.31 (0.25-0.97), respectively. CONCLUSION PBCC in preterm infants using the Concord is feasible. HR remained stable, and SpO2 quickly increased with low levels of oxygen supply. TRIAL REGISTRATION NUMBER NTR6095, results.
Collapse
Affiliation(s)
- Emma Brouwer
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands,Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Alex S N Vernooij
- Department of Medical Engineering, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Patricia E Vlasman
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Philip DeKoninck
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Arjan B te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
44
|
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: 21] [Impact Index Per Article: 4.2] [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.
Collapse
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
| |
Collapse
|
45
|
Pahuja A, Hunt K, Murthy V, Bhat P, Bhat R, Milner AD, Greenough A. Relationship of resuscitation, respiratory function monitoring data and outcomes in preterm infants. Eur J Pediatr 2018; 177:1617-1624. [PMID: 30066181 DOI: 10.1007/s00431-018-3222-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022]
Abstract
Intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD) are major complications of premature birth. We tested the hypotheses that prematurely born infants who developed an IVH or BPD would have high expiratory tidal volumes (VTE) (VTE > 6 ml/kg) and/or low-end tidal carbon dioxide (ETCO2) levels (ETCO2 levels < 4.5 kPa) as recorded by respiratory function monitoring or hyperoxia (oxygen saturation (SaO2) > 95%) during resuscitation in the delivery suite. Seventy infants, median gestational age 27 weeks (range 23-33), were assessed; 31 developed an IVH and 43 developed BPD. Analysis was undertaken of 31,548 inflations. The duration of resuscitation did not differ significantly between the groups. Those who developed an IVH compared to those who did not had a greater number of inflations with a high VTE and a low ETCO2, which remained significant after correcting for differences in gestational age and birth weight between groups (p = 0.019). Differences between infants who did and did not develop BPD were not significant after correcting for differences in gestational age and birth weight. There were no significant differences in the duration of hyperoxia between the groups.Conclusions: Avoidance of high tidal volumes and hypocarbia in the delivery suite might reduce IVH development. What is known • Hypocarbia on the neonatal unit is associated with the development of intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD). What is new • Infants who developed an IVH compared to those who did not had significantly more inflations with high expiratory tidal volumes and low ETCO2s.
Collapse
Affiliation(s)
- Anoop Pahuja
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Katie Hunt
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Prashanth Bhat
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust, King's College London, London, UK.
| |
Collapse
|
46
|
Viaroli F, Cheung PY, O'Reilly M, Polglase GR, Pichler G, Schmölzer GM. Reducing Brain Injury of Preterm Infants in the Delivery Room. Front Pediatr 2018; 6:290. [PMID: 30386757 PMCID: PMC6198082 DOI: 10.3389/fped.2018.00290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/19/2018] [Indexed: 11/13/2022] Open
Abstract
Cerebrovascular injury is one of the major detrimental consequences of preterm birth. Recent studies have focused their attention on factors that contribute to the development of brain lesions immediately after birth. Among those factors, hypothermia and lower cerebral oxygen saturation during delivery room resuscitation and high tidal volumes delivered during respiratory support are associated with increased risk of severe neurologic injury. In preterm infants, knowledge about causes and prevention of brain injury must be applied before and at birth. Preventive and therapeutic approaches, including correct timing of cord clamping, monitoring of physiological changes during delivery room resuscitation using pulse oximetry, respiratory function monitoring, near infrared spectroscopy, and alpha EEG, may minimize brain injury, Furthermore, postnatal administration of caffeine or other potential novel treatments (e.g., proangiogenic therapies, antioxidants, hormones, or stem cells) might improve long-term neurodevelopmental outcomes in preterm infants.
Collapse
Affiliation(s)
- Francesca Viaroli
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Gerhard Pichler
- Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|