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Bellos I, Pillai A, Pandita A. Providing Positive End-Expiratory Pressure during Neonatal Resuscitation: A Meta-analysis. Am J Perinatol 2024; 41:690-699. [PMID: 36041471 DOI: 10.1055/a-1933-7235] [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] [Indexed: 11/01/2022]
Abstract
Our objective was to conduct a systematic review and meta-analysis evaluating the effects of administering positive end-expiratory pressure (PEEP) during neonatal resuscitation at birth. Medline, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases were systematically searched from inception to 15 December 2020. Randomized controlled trials and cohort studies were held eligible. Studies were included if they compared the administration of PEEP using either a T-piece resuscitator or a self-inflating bag with a PEEP valve versus resuscitation via a self-inflating bag without a PEEP valve. Data were extracted by two reviewers independently. The credibility of evidence was appraised with the Grading of Recommendations, Assessment, Development, and Evaluations approach. Random-effects models were fitted to provide pooled estimates of risk ratio (RR) and 95% confidence intervals (CIs). Overall, 10 studies were included, comprising 4,268 neonates. This included five randomized controlled trials, one quasi-randomized trial, and four cohort studies. The administration of PEEP was associated with significantly lower rates of mortality till discharge (odds ratio [OR]: 0.60, 95% CI: 0.49-0.74, moderate quality of evidence). The association was significant in preterm (OR: 0.57, 95% CI: 0.46-0.69) but not in term (OR: 1.03, 95% CI: 0.52-2.02) neonates. Low-to-moderate quality evidence suggests that providing PEEP during neonatal resuscitation is associated with lower rates of mortality in preterm neonates. Evidence regarding term neonates is limited and inconclusive. Future research is needed to determine the optimal device and shed more light on the long-term effects of PEEP administration during neonatal resuscitation. This study is registered with PROSPERO with registration number: CRD42020219956. KEY POINTS: · PEEP administration during neonatal resuscitation in the delivery room reduces mortality in preterm.. · Evidence regarding term neonates is limited and inconclusive.. · Future research is needed to determine the optimal device..
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Division of Surgery, Athens University Medical School, National and Kapodistrian University of Athens, Greece
| | - Anish Pillai
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Aakash Pandita
- Department of Neonatology, Medanta Hospital, Lucknow, Uttar Pradesh, India
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Kuypers KLAM, Kashyap AJ, Cramer SJE, Hooper SB, Te Pas AB. The effect of imposed resistance in neonatal resuscitators on pressure stability and peak flows: a bench test. Pediatr Res 2023; 94:1929-1934. [PMID: 37460710 DOI: 10.1038/s41390-023-02715-x] [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: 02/25/2023] [Revised: 06/01/2023] [Accepted: 06/14/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND The importance of neonatal resuscitator resistance is currently unknown. In this study we investigated peak flows and pressure stability resulting from differences in imposed resistance during positive pressure ventilation(PPV) and simulated spontaneous breathing (SSB) between the r-PAP, low-resistance resuscitator, and Neopuff™, high-resistance resuscitator. METHODS In a bench test, 20 inflations during PPV and 20 breaths during SSB were analysed on breath-by-breath basis to determine peak flow and pressure stability using the Neopuff™ with bias gas flow of 8, 12 or 15 L/min and the r-PAP with total gas flow of 15 L/min. RESULTS Imposed resistance of the Neopuff™ was significantly reduced when the bias gas flow was increased from 8 to 15 L/min, which resulted in higher peak flows during PPV and SSB. Peak flows in the r-PAP were, however, significantly higher and fluctuations in CPAP during SSB were significantly smaller in the r-PAP compared to the Neopuff™ for all bias gas flow levels. During PPV, a pressure overshoot of 3.2 cmH2O was observed in the r-PAP. CONCLUSIONS The r-PAP seemed to have a lower resistance than the Neopuff™ even when bias gas flows were increased. This resulted in more stable CPAP pressures with higher peak flows when using the r-PAP. IMPACT The traditional T-piece system (Neopuff™) has a higher imposed resistance compared to a new neonatal resuscitator (r-PAP). This study shows that reducing imposed resistance leads to smaller CPAP fluctuations and higher inspiratory and expiratory peak flows. High peak flows might negatively affect lung function and/or cause lung injury in preterm infants at birth. This study will form the rationale for further studies investigating these effects. A possible compromise might be to use the traditional T-piece system with a higher bias gas flow (12 L/min), thereby reducing the imposed resistance and generating more stable PEEP/CPAP pressures, while limiting potentially harmful peak flows.
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Affiliation(s)
- Kristel L A M Kuypers
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Aidan J Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Sophie J E Cramer
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
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Pallapothu B, Priyadarshi M, Singh P, Kumar S, Chaurasia S, Basu S. T-Piece resuscitator versus self-inflating bag for delivery room resuscitation in preterm neonates: a randomized controlled trial. Eur J Pediatr 2023; 182:5565-5576. [PMID: 37792092 DOI: 10.1007/s00431-023-05230-7] [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: 08/16/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
The establishment of adequate ventilation is the cornerstone of neonatal resuscitation in the delivery room (DR). This parallel-group, accessor-blinded randomized controlled trial compared the changes in peripheral oxygen saturation (SpO2), heart rate (HR), and cerebral regional oxygen saturation (crSO2) with the use of a T-piece resuscitator (TPR) versus self-inflating bag (SIB) as a mode of providing positive pressure ventilation (PPV) during DR resuscitation in preterm neonates. Seventy-two preterm neonates were randomly allocated to receive PPV with TPR (n = 36) or SIB (n = 36). The primary outcome was SpO2 (%) at 5 min. The secondary outcomes included the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, fractional-inspired oxygen (FiO2) requirement, minute-specific SpO2, HR and FiO2 trends for the first 5 min of life, need for DR-intubation, crSO2, need and duration of respiratory support, and other in-hospital morbidities. Mean SpO2 at 5 min was 74.5 ± 17.8% and 69.4 ± 22.4%, in TPR and SIB groups, respectively [Mean difference, 95% Confidence Interval 5.08 (-4.41, 14.58); p = 0.289]. No difference was observed in the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, the requirement of FiO2, DR-intubation, and the need and duration of respiratory support. There was no significant difference in the minute-specific SpO2, HR, and FiO2 requirements for the first 5 min. CrSO2 (%) at one hour was lower by 5% in the TPR group compared to SIB; p = 0.03. Other complications were comparable. CONCLUSIONS TPR and SIB resulted in comparable SpO2 at 5 min along with similar minute-specific SpO2, HR, and FiO2 trends. CLINICAL TRIAL REGISTRATION Clinical trial registry of India, Registration no: CTRI/2021/10/037384, Registered prospectively on: 20/10/2021, https://ctri.icmr.org.in/ . WHAT IS KNOWN • Compared to self-inflating bags (SIB), T-piece resuscitators (TPR) provide more consistent inflation pressure and tidal volume as shown in animal and bench studies. • There is no strong recommendation for one device over the other in view of low certainty evidence. WHAT IS NEW • TPR and SIB resulted in comparable peripheral oxygen saturation (SpO2) at 5 min along with similar minute-specific SpO2, heart rate, and fractional-inspired oxygen requirement trends. • Short-term complications and mortality rates were comparable with both devices.
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Affiliation(s)
- Bhrajishna Pallapothu
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Mayank Priyadarshi
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Poonam Singh
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Sourabh Kumar
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Suman Chaurasia
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Sriparna Basu
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
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Drevhammar T, Bjorland PA, Haynes J, Eilevstjønn J, Hinder M, Tracy M, Rettedal SI, Ersdal HL. Incomplete Exhalation during Resuscitation-Theoretical Review and Examples from Ventilation of Newborn Term Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1118. [PMID: 37508615 PMCID: PMC10377906 DOI: 10.3390/children10071118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Newborn resuscitation guidelines recommend positive pressure ventilation (PPV) for newborns who do not establish effective spontaneous breathing after birth. T-piece resuscitator systems are commonly used in high-resource settings and can additionally provide positive end-expiratory pressure (PEEP). Short expiratory time, high resistance, rapid dynamic changes in lung compliance and large tidal volumes increase the possibility of incomplete exhalation. Previous publications indicate that this may occur during newborn resuscitation. Our aim was to study examples of incomplete exhalations in term newborn resuscitation and discuss these against the theoretical background. METHODS Examples of flow and pressure data from respiratory function monitors (RFM) were selected from 129 term newborns who received PPV using a T-piece resuscitator. RFM data were not presented to the user during resuscitation. RESULTS Examples of incomplete exhalation with higher-than-set PEEP-levels were present in the recordings with visual correlation to factors affecting time needed to complete exhalation. CONCLUSIONS Incomplete exhalation and the relationship to expiratory time constants have been well described theoretically. We documented examples of incomplete exhalations with increased PEEP-levels during resuscitation of term newborns. We conclude that RFM data from resuscitations can be reviewed for this purpose and that incomplete exhalations should be further explored, as the clinical benefit or risk of harm are not known.
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Affiliation(s)
- Thomas Drevhammar
- Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | | | - Joanna Haynes
- Department of Anaesthesia, Stavanger University Hospital, 4019 Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway
| | - Joar Eilevstjønn
- Laerdal Medical, Strategic Research Department, 4007 Stavanger, Norway
| | - Murray Hinder
- Department of Paediatrics and Child Health, Sydney University, Westmead, Sydney, NSW 2006, Australia
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
| | - Mark Tracy
- Department of Paediatrics and Child Health, Sydney University, Westmead, Sydney, NSW 2006, Australia
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
| | - Siren Irene Rettedal
- Department of Paediatrics, Stavanger University Hospital, 4019 Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway
| | - Hege Langli Ersdal
- Department of Anaesthesia, Stavanger University Hospital, 4019 Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway
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Bresesti I, Cavigioli F, Scrivens A, Lista G, Chaban B, Roehr CC, Zivanovic S. Pressure and tidal volume delivery in extremely preterm infants at birth using different t-piece resuscitation devices. Early Hum Dev 2023; 183:105794. [PMID: 37295264 DOI: 10.1016/j.earlhumdev.2023.105794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
Infants <28 weeks' gestation in need of inflations at birth were recorded with Respiratory Function Monitor. Two devices were used for resuscitation. Peak Inspiratory Pressure spikes were visible in all inflations with GE Panda and in none with Neo-Puff. There was no significant difference in mean Vte/kg between GE Panda and Neo-Puff.
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Affiliation(s)
- Ilia Bresesti
- Newborn Services, John Radcliffe Hospital, Oxford University Hospital, Oxford, UK; Division of Neonatology, Department of Woman and Child, ASST Settelaghi, University of Insubria, Varese, Italy
| | | | - Alexandra Scrivens
- Newborn Services, John Radcliffe Hospital, Oxford University Hospital, Oxford, UK
| | - Gianluca Lista
- NICU "V. Buzzi" Children's Hospital, ASST FBF-Sacco, Milan, Italy
| | - Badr Chaban
- Imperial Neonatal Service, Imperial College Healthcare NHS Trust, London, UK
| | - Charles C Roehr
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Sanja Zivanovic
- Newborn Services, John Radcliffe Hospital, Oxford University Hospital, Oxford, UK; Department of Paediatrics, Division of Medical Sciences, University of Oxford, Oxford, UK.
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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.
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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
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Shah D, Tracy M, Hinder M, Badawi N. Positive end expiratory pressure and respiratory system resistance between self-inflating bag and T-piece resuscitator in a cadaveric piglet lung model. Front Pediatr 2022; 10:1014311. [PMID: 36467494 PMCID: PMC9714259 DOI: 10.3389/fped.2022.1014311] [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: 08/08/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In neonatal resuscitation, T-piece resuscitator (TPR) are used widely, but the evidence is limited for their use in infants born at term gestation. The aim of this study was to compare the delivered positive end expiratory pressure (PEEP) and respiratory system resistance (Rrs) using TPR and self-inflating bag (SIB) in a cadaveric piglet model. METHODS Cadaveric newborn piglets were tracheotomised, intubated (cuffed tube) and leak tested. Static lung compliance was measured. Positive pressure ventilation was applied by TPR and SIB in a randomized sequence with varying, inflations per minute (40, 60 and 80 min) and peak inspiratory pressures (18 and 30 cmH2O). PEEP was constant at 5 cmH2O. The lungs were washed with saline and static lung compliance was re-measured; ventilation sequences were repeated. Lung inflation data for the respiratory mechanics were measured using a respiratory function monitor and digitally recorded for both pre and post-lung wash inflation sequences. A paired sample t-test was used to compare the mean and standard deviation. RESULTS The mean difference in PEEP (TPR vs. SIB) was statistically significant at higher inflation rates of 60 and 80 bpm. At normal lung compliance, mean difference was 1.231 (p = 0.000) and 2.099 (p = 0.000) with PIP of 18 and 30 cmH2O respectively. Significantly higher Rrs were observed when using a TPR with higher inflation rates of 60 and 80 bpm at varying lung compliance. CONCLUSION TPR is associated with significantly higher PEEP in a compliant lung model, which is probably related to the resistance of the TPR circuit. The effect of inadvertent PEEP on lung mechanics and hemodynamics need to be examined in humans. Further studies are needed to assess devices used to provide PEEP (TPR, SIB with PEEP valve, Anaesthetic bag with flow valve) during resuscitation of the newborn.
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Affiliation(s)
- Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Mark Tracy
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Murray Hinder
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nadia Badawi
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, NSW, Australia.,Cerebral Palsy Alliance Research Institute, University of Sydney, Sydney, NSW, Australia
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Kuypers KLAM, Willemsen LA, Cramer SJE, Kashyap AJ, Drevhammar T, Hooper SB, Te Pas AB. The Effect of a Higher Bias Gas Flow on Imposed T-Piece Resistance and Breathing in Preterm Infants at Birth. Front Pediatr 2022; 10:817010. [PMID: 35372143 PMCID: PMC8968754 DOI: 10.3389/fped.2022.817010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/21/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The resistance created by the PEEP-valve of a T-piece resuscitator is bias gas flow dependent and might affect breathing in preterm infants. In this study we investigated the effect of a higher bias gas flow on the imposed inspiratory and expiratory T-piece resistance and expiratory breaking manoeuvres (EBM) in preterm infants during spontaneous breathing on CPAP at birth. METHODS In a retrospective pre-post implementation study of preterm infants <32 weeks gestation, who were stabilised with a T-piece resuscitator, a bias gas flow of 12 L/min was compared to 8 L/min. All spontaneous breaths on CPAP within the first 10 min of starting respiratory support were analysed on a breath-by-breath basis to determine the breathing pattern of each breath and to calculate the imposed inspiratory and expiratory T-piece resistance (Ri, Re), flow rates and tidal volume. RESULTS In total, 54 infants were included (bias gas flow 12 L/min: n = 27, 8 L/min: n = 27) with a median GA of 29+6 (28+4-30+3) and 28+5 (25+6-30+3), respectively (p = 0.182). Ri and Re were significantly lower in the 12 L/min compared to 8 L/min bias flow group [Ri: 29.6 (26.1-33.6) vs. 46.4 (43.0-54.1) cm H2O/L/s, p < 0.001; Re: 32.0 (30.0-35.1) vs. 48.0 (46.3-53.9) cm H2O/L/s, p < 0.001], while the incidence of EBM [77% (53-88) vs. 77% (58-90), p = 0.586] was similar. CONCLUSION During stabilisation of preterm infants at birth with a T-piece resuscitator, the use of a higher bias gas flow reduced both the imposed inspiratory and expiratory T-piece resistance for the infant, but this did not influence the incidence of EBMs.
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Affiliation(s)
- Kristel L A M Kuypers
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, Netherlands
| | - Lieve A Willemsen
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, Netherlands
| | - Sophie J E Cramer
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, Netherlands
| | - Aidan J Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Thomas Drevhammar
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Anaesthesiology, Östersund Hospital, Östersund, Sweden
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, Netherlands
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Circulation 2021; 145:e645-e721. [PMID: 34813356 DOI: 10.1161/cir.0000000000001017] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami M, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2021; 169:229-311. [PMID: 34933747 PMCID: PMC8581280 DOI: 10.1016/j.resuscitation.2021.10.040] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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11
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Trevisanuto D, Roehr CC, Davis PG, Schmölzer GM, Wyckoff MH, Liley HG, Rabi Y, Weiner GM. Devices for Administering Ventilation at Birth: A Systematic Review. Pediatrics 2021; 148:peds.2021-050174. [PMID: 34135096 DOI: 10.1542/peds.2021-050174] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation. OBJECTIVE To compare T-piece resuscitators (TPRs), self-inflating bags (SIBs), and flow-inflating bags for newborns receiving PPV during delivery room resuscitation. DATA SOURCES Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, and trial registries (inception to December 2020). STUDY SELECTION Randomized, quasi-randomized, interrupted time series, controlled before-and-after, and cohort studies were included without language restrictions. DATA EXTRACTION Two researchers independently extracted data, assessed the risk of bias, and evaluated the certainty of evidence. The primary outcome was in-hospital mortality. When appropriate, data were pooled by using fixed-effect models. RESULTS Meta-analysis of 4 randomized controlled trials (1247 patients) revealed no significant difference between TPR and SIB for in-hospital mortality (risk ratio 0.74; 95% confidence interval [CI] 0.40 to 1.34). Resuscitation with a TPR resulted in a shorter duration of PPV (mean difference -19.8 seconds; 95% CI -27.7 to -12.0 seconds) and lower risk of bronchopulmonary dysplasia (risk ratio 0.64; 95% CI 0.43 to 0.95; number needed to treat 32). No differences in clinically relevant outcomes were found in 2 randomized controlled trials used to compare SIBs with and without positive end-expiratory pressure valves. No studies used to evaluate flow-inflating bags were found. LIMITATIONS Certainty of evidence was very low or low for most outcomes. CONCLUSIONS Resuscitation with a TPR compared with an SIB reduces the duration of PPV and risk of bronchopulmonary dysplasia. A strong recommendation cannot be made because of the low certainty of evidence. There is insufficient evidence to determine the effectiveness of positive end-expiratory pressure valves when used with SIBs.
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Affiliation(s)
- Daniele Trevisanuto
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, National Health Service Foundation Trust, Oxford, United Kingdom.,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Georg M Schmölzer
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Myra Helen Wyckoff
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Helen G Liley
- Mater Research Institute and Mater Clinical Unit, School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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12
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Hinder M, Tracy M. Newborn resuscitation devices: The known unknowns and the unknown unknowns. Semin Fetal Neonatal Med 2021; 26:101233. [PMID: 33773952 DOI: 10.1016/j.siny.2021.101233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Infant resuscitation devices used at birth must be capable of delivering adequate and consistent ventilation in a controlled and predictable manner to a wide patient weight range, and combinations of transitional lung states. Manual inflation resuscitation devices delivering positive pressure lung inflation at birth can be classified broadly into two types: 1) flow generating, ie silicone self-inflating bags (SIB) also known as bag valve mask (BVM) and 2) flow dependent, ie anaesthetic flow inflating bag (FIB) and t-piece resuscitator (TPR) systems (eg: Neopuff, GE Panda and Draeger Resuscitaires). Globalization, lower production costs, and an expanding market need for devices, has led to a proliferation of brands (both reusable and single use) within a class type. T-piece resuscitators have become the dominant device particularly in high income countries. There remains a paucity of information on the performance characteristics of these devices and their ability to provide the required respiratory parameters for effective and safe ventilation across the full-expected weight range and lung states to which they will be applied. This review aims to inform current clinical practise on the biomechanical efficiency, reliability and efficacy of the most common devices used to apply PPV to newborns and infants ≤10 kgs.
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Affiliation(s)
- Murray Hinder
- The Westmead Hospital Neonatal Intensive Care Unit, Australia; The University of Sydney, Department of Paediatrics and Child Health, Australia
| | - Mark Tracy
- The Westmead Hospital Neonatal Intensive Care Unit, Australia; The University of Sydney, Department of Paediatrics and Child Health, Australia.
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13
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European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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14
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Roehr CC, Davis PG, Weiner GM, Jonathan Wyllie J, Wyckoff MH, Trevisanuto D. T-piece resuscitator or self-inflating bag during neonatal resuscitation: a scoping review. Pediatr Res 2021; 89:760-766. [PMID: 32526766 DOI: 10.1038/s41390-020-1005-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To identify the evidence for administering positive pressure ventilation (PPV) to infants at birth by either T-piece resuscitator (TPR) or self-inflating bag (SIB), and to determine whether a full systematic review (SR) is warranted. METHODS Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews, eligible studies included peer-reviewed human studies, prospectively or retrospectively comparing a TPR vs. SIB for administering PPV at birth. Databases searched were OVID Medline, PubMed, Embase and the Cochrane Central Register of Controlled Trials. Review Manager software was used for the data analysis. RESULTS Following electronic literature search and review, data from four eligible studies (3 RCT and 1 observational study), enrolling a total of 2889 patients, were included. Studies differed regarding the investigated populations, reported outcomes and came from different geographical areas. In particular for preterm infants, use of TPR for providing PPV may improve survival, result in fewer intubations at birth and decrease the incidence of bronchopulmonary dysplasia. CONCLUSIONS This scoping review identified two new studies with substantive new evidence, pointing towards improved survival, decreased bronchopulmonary dysplasia and fewer intubations at birth, in particular among preterm infants treated with TPR. Full SR of the literature is advised. IMPACT This scoping review identified studies comparing TPR vs. SIB for respiratory support of newborn infants previously not included in the International Liaison Committee on Resuscitation (ILCOR) recommendations. Our review found substantive new evidence highlighting that device choice may impact the outcomes of compromised newborn infants'. This scoping review stipulates the need for full SR and updated meta-analysis of studies investigating supportive equipment for stabilizing infants at birth in order to inform ILCOR treatment recommendations.
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Affiliation(s)
- Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK. .,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK.
| | - Peter Graham Davis
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
| | - Gary Marshall Weiner
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - J Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
| | - Myra Helen Wyckoff
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daniele Trevisanuto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
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15
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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.
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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
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Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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17
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Drevhammar T, Falk M, Donaldsson S, Tracy M, Hinder M. Neonatal Resuscitation With T-Piece Systems: Risk of Inadvertent PEEP Related to Mechanical Properties. Front Pediatr 2021; 9:663249. [PMID: 34164358 PMCID: PMC8215339 DOI: 10.3389/fped.2021.663249] [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: 02/02/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Resuscitation of infants using T-piece resuscitators (TPR) allow positive pressure ventilation with positive end-expiratory pressure (PEEP). The adjustable PEEP valve adds resistance to expiration and could contribute to inadvertent PEEP. The study indirectly investigated risk of inadvertent peep by determining expiratory time constants. The aim was to measure system expiratory time constants for a TPR device in a passive mechanical model with infant lung properties. Methods: We used adiabatic bottles to generate four levels of compliance (0.5-3.4 mL/cm H2O). Expiratory time constants were recorded for combinations of fresh gas flow (8, 10, 15 L/min), PEEP (5, 8, 10 cm H2O), airway resistance (50, 200 cm H2O/L/sec and none), endotracheal tube (none, size 2.5, 3.0, 3.5) with a peak inflation pressure of 15 cm H2O above PEEP. Results: Low compliances resulted in time constants below 0.17 s contrasting to higher compliances where the expiratory time constants were 0.25-0.81 s. Time constants increased with increased resistance, lower fresh gas flows, higher set PEEP levels and with an added airway resistance or endotracheal tube. Conclusions: The risk of inadvertent PEEP increases with a shorter time for expiration in combination with a higher compliance or resistance. The TPR resistance can be reduced by increasing the fresh gas flow or reducing PEEP. The expiratory time constants indicate that this may be clinically important. The risk of inadvertent PEEP would be highest in intubated term infants with highly compliant lungs. These results are useful for interpreting clinical events and recordings.
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Affiliation(s)
- Thomas Drevhammar
- Anaesthesiology and Intensive Care Medicine, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Markus Falk
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Snorri Donaldsson
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Neonatology Department, Karolinska University Hospital, Stockholm, Sweden
| | - Mark Tracy
- Department of Pediatrics and Child Health, The University of Sydney, Sydney, NSW, Australia.,Neonatal Intensive Care Unit, Westmead Hospital, Sydney, NSW, Australia
| | - Murray Hinder
- Department of Pediatrics and Child Health, The University of Sydney, Sydney, NSW, Australia.,Neonatal Intensive Care Unit, Westmead Hospital, Sydney, NSW, Australia
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18
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Hinder M, Drevhammar T, Donaldsson S, Boustred M, Crott M, Tracy MB. T-piece resuscitators: What you set is often not what gets delivered or measured. Arch Dis Child Fetal Neonatal Ed 2021; 106:110-111. [PMID: 33082152 DOI: 10.1136/archdischild-2020-320457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Murray Hinder
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia .,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.,Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
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19
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Holte K, Ersdal H, Eilevstjønn J, Gomo Ø, Klingenberg C, Thallinger M, Linde J, Stigum H, Yeconia A, Kidanto H, Størdal K. Positive End-Expiratory Pressure in Newborn Resuscitation Around Term: A Randomized Controlled Trial. Pediatrics 2020; 146:peds.2020-0494. [PMID: 32917847 DOI: 10.1542/peds.2020-0494] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND International guidelines for resuscitation recommend using positive end-expiratory pressure (PEEP) during ventilation of preterm newborns. Reliable PEEP-valves for self-inflating bags have been lacking, and effects of PEEP during resuscitation of term newborns are insufficiently studied. The objective was to determine if adding a new PEEP valve to the bag-mask during resuscitation of term and near-term newborns could improve heart rate response. METHODS This randomized controlled trial was performed at Haydom Lutheran Hospital in Tanzania (September 2016 to June 2018). Helping Babies Breathe-trained midwives performed newborn resuscitation using self-inflating bags with or without a new, integrated PEEP valve. All live-born newborns who received bag-mask ventilation at birth were eligible. Heart rate response measured by ECG was the primary outcome, and clinical outcome and ventilation data were recorded. RESULTS Among 417 included newborns (median birth weight 3200 g), 206 were ventilated without and 211 with PEEP. We found no difference in heart rate response. Median (interquartile range) measured PEEP in the PEEP group was 4.7 (2.0-5.6) millibar. The PEEP group received lower tidal volumes (4.9 [1.9-8.2] vs 6.3 [3.9-10.5] mL/kg; P = .02) and had borderline lower expired CO2 (2.9 [1.5-4.3] vs 3.3 [1.9-5.0] %; P = .05). Twenty four-hour mortality was 9% in both groups. CONCLUSIONS We found no evidence for improved heart rate response during bag-mask ventilation with PEEP compared with no PEEP. The PEEP valve delivered a median PEEP within the intended range. The findings do not support routine use of PEEP during resuscitation of newborns around term.
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Affiliation(s)
- Kari Holte
- Department of Pediatrics and Adolescence Medicine, Østfold Hospital Trust, Grålum, Norway; .,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Departments of Anesthesiology and Intensive Care
| | - Joar Eilevstjønn
- Strategic Research Department, Laerdal Medical, Stavanger, Norway
| | - Øystein Gomo
- Strategic Research Department, Laerdal Medical, Stavanger, Norway
| | - Claus Klingenberg
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway.,Pediatric Research Group, Faculty of Health Sciences, University of Tromsø-Arctic University of Norway, Tromsø, Norway
| | - Monica Thallinger
- Department of Anesthesiology and Intensive Care, Vestre Viken Hospital Trust, Bærum, Norway
| | - Jørgen Linde
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Pediatrics and Adolescence Medicine, and
| | - Hein Stigum
- Norwegian Institute of Public Health, Oslo, Norway
| | - Anita Yeconia
- Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania; and
| | - Hussein Kidanto
- Research, Stavanger University Hospital, Stavanger, Norway.,Medical College, Agakhan University, Dar es Salaam, Tanzania
| | - Ketil Størdal
- Department of Pediatrics and Adolescence Medicine, Østfold Hospital Trust, Grålum, Norway.,Norwegian Institute of Public Health, Oslo, Norway
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20
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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.
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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
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21
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de Groene L, De Jaegere AP, Nijland OJ, van Kaam AH. Validation of the disposable T-piece resuscitator (Neo-Tee): a bench study. Arch Dis Child Fetal Neonatal Ed 2019; 104:F594-F597. [PMID: 30782967 DOI: 10.1136/archdischild-2018-315298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 12/07/2018] [Accepted: 12/20/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Neo-Tee Infant T-piece resuscitator is a disposable T-piece resuscitator. The aim of this bench study was to assess the accuracy of the Neo-Tee using a measurement set-up and settings mimicking clinical practice. STUDY DESIGN Nine Neo-Tee devices were tested using a face mask interface and a manikin. Pressures were set using the built-in manometer and simultaneously measured at the interface. Peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) were studied under static conditions and positive pressure ventilation (PPV), using a wide range of clinically relevant flows and pressures. Pressures were measured without adjusting for a possible offset of PIP and PEEP after switching from static pressures to PPV. In an additional subset of measurements, PIP/PEEP offsets on the Neo-Tee manometer after starting PPV were adjusted. RESULTS Under static conditions, setting the PEEP level with the Neo-Tee manometer results in overestimation of the true PEEP applied at the airway opening, with a difference of approximately 1.5 cmH2O. When switching to PPV, this difference almost disappears. In contrast to PEEP, PIP levels measured at the airway opening were accurate.Adjusting PIP and PEEP on the built-in manometer after starting PPV was necessary in all measurements, but this did not improve the accuracy of the targeted pressure delivery, especially for PEEP. A gas flow rate of 5 L/min was insufficient to reach commonly used PEEP levels of 5 cmH2O. CONCLUSION The Neo-Tee T-piece resuscitator is accurate for delivering a static inflation and PPV, but not for delivering continuous positive airway pressure.
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Affiliation(s)
- Lizzy de Groene
- Department of Anaesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anne P De Jaegere
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier J Nijland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Ellsworth L, Meerkov M, Doglioni N, Trevisanuto D, Weiner G. Oxygen supplementation in the delivery room: T-piece resuscitator cap open or occluded? J Perinatol 2019; 39:1078-1080. [PMID: 31209277 DOI: 10.1038/s41372-019-0406-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/10/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Updated neonatal resuscitation guidelines for free-flow oxygen administration with a T-piece resuscitator recommend higher gas flow and an open T-piece cap. We aimed to determine the effect of gas inflow rate and cap occlusion on oxygen delivery through a T-piece resuscitator. STUDY DESIGN Using a NeoPuff™ T-piece, oxygen inflow was randomly adjusted from 4 to 10 liters per minute (LPM). Gas outflow and oxygen concentration were measured with the T-piece cap open and occluded. Data were analyzed with repeated measures 2-way ANOVA. RESULT Gas outflow was significantly decreased with the T-piece cap open compared with occluded at each inflow rate (p < 0.001). There was no difference in oxygen concentration of the outflow gas. CONCLUSION Gas flow from the T-piece is affected by the inflow rate and cap occlusion but oxygen concentration is not. To deliver 5 LPM of free-flow oxygen with the cap open, a minimum of 8 LPM gas inflow is required.
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Affiliation(s)
- Lindsay Ellsworth
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Meera Meerkov
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Nicoletta Doglioni
- Neonatal Intensive Care Unit - Women and Child Health Department, University of Padova-Azienda Ospedaliera Di Padova, Padova, Italy
| | - Daniele Trevisanuto
- Neonatal Intensive Care Unit - Women and Child Health Department, University of Padova-Azienda Ospedaliera Di Padova, Padova, Italy
| | - Gary Weiner
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Guinsburg R, Miyoshi MH, de Almeida MFB. T-piece resuscitators: a warning sign. Arch Dis Child Fetal Neonatal Ed 2019; 104:F116-F117. [PMID: 29954882 DOI: 10.1136/archdischild-2018-315372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/12/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Milton Harumi Miyoshi
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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