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Hodgson KA, Selvakumaran S, Francis KL, Owen LS, Newman SE, Kamlin COF, Donath S, Roberts CT, Davis PG, Manley BJ. Predictors of successful neonatal intubation in inexperienced operators: a secondary, non-randomised analysis of the SHINE trial. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-327081. [PMID: 38969493 DOI: 10.1136/archdischild-2024-327081] [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: 02/28/2024] [Accepted: 06/06/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE Neonatal endotracheal intubation is a lifesaving but technically difficult procedure, particularly for inexperienced operators. This secondary analysis in a subgroup of inexperienced operators of the Stabilization with nasal High flow during Intubation of NEonates randomised trial aimed to identify the factors associated with successful intubation on the first attempt without physiological stability of the infant. METHODS In this secondary analysis, demographic factors were compared between infants intubated by inexperienced operators and those intubated by experienced operators. Following this, for inexperienced operators only, predictors of successful intubation without physiological instability were analysed. RESULTS A total of 251 intubations in 202 infants were included in the primary intention-to-treat analysis of the main trial. Inexperienced operators were more likely to perform intubations in larger and more mature infants in the neonatal intensive care unit where premedications were used. When intubations were performed by inexperienced operators, the use of nasal high flow therapy (nHF) and a higher starting fraction of inspired oxygen were associated with a higher rate of safe, successful intubation on the first attempt. There was a weaker association between premedication use and first attempt success. CONCLUSIONS In inexperienced operators, this secondary, non-randomised analysis suggests that the use of nHF and premedications, and matching the operator to the infant and setting, may be important to optimise neonatal intubation success. TRIAL REGISTRATION NUMBER ACTRN12618001498280.
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Affiliation(s)
- Kate Alison Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sharoan Selvakumaran
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Kate Louise Francis
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie E Newman
- Department of Neonatal Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Camille Omar Farouk Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Susan Donath
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Calum T Roberts
- Department of Paediatrics, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Parkville, Victoria, Australia
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Trevisanuto D, Gizzi C, Cavallin F, Beke A, Buonocore G, Charitou A, Cucerea M, Filipović-Grčić B, Jekova NG, Koç E, Saldanha J, Stoniene D, Varendi H, De Bernardo G, Madar J, Hogeveen M, Orfeo L, Mosca F, Vertecchi G, Moretti C. Laryngeal Mask Airway in Neonatal Resuscitation: A Survey of the Union of European Neonatal and Perinatal Societies. Neonatology 2024:1-11. [PMID: 38834044 DOI: 10.1159/000538808] [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: 11/17/2023] [Accepted: 04/08/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Laryngeal mask airway (LMA) use in neonatal resuscitation is limited despite existing evidence and recommendations. This survey investigated the knowledge and experience of healthcare providers on the use of the LMA and explored barriers and solutions for implementation. METHODS This online, cross-sectional survey on LMA in neonatal resuscitation involved healthcare professionals of the Union of European Neonatal and Perinatal Societies (UENPS). RESULTS A total of 858 healthcare professionals from 42 countries participated in the survey. Only 6% took part in an LMA-specific course. Some delivery rooms were not equipped with LMA (26.1%). LMA was mainly considered after the failure of a face mask (FM) or endotracheal tube (ET), while the first choice was limited to neonates with upper airway malformations. LMA and FM were considered easier to position but less effective than ET, while LMA was considered less invasive than ET but more invasive than FM. Participants felt less competent and experienced with LMA than FM and ET. The lack of confidence in LMA was perceived as the main barrier to its implementation in neonatal resuscitation. More training, supervision, and device availability in delivery wards were suggested as possible actions to overcome those barriers. CONCLUSION Our survey confirms previous findings on limited knowledge, experience, and confidence with LMA, which is usually considered an option after the failure of FM/ET. Our findings highlight the need for increasing the availability of LMA in delivery wards. Moreover, increasing LMA training and having an LMA expert supervisor during clinical practice may improve the implementation of LMA use in neonatal clinical practice.
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Affiliation(s)
- Daniele Trevisanuto
- Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Camilla Gizzi
- Department of Neonatology and NICU, Ospedale Sant'Eugenio, Rome, Italy
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
| | | | - Artur Beke
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Giuseppe Buonocore
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Antonia Charitou
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Neonatal Department and Neonatal Intensive Care Unit, Rea Maternity Hospital, Athens, Greece
| | - Manuela Cucerea
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Neonatology Department, University of Medicine Pharmacy Science and Technology "George Emil Palade", Târgu Mures, Romania
| | - Boris Filipović-Grčić
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Pediatrics, University of Zagreb School of Medicine, HR, Zagreb, Croatia
| | - Nelly Georgieva Jekova
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Pediatrics, University Hospital "Majchin Dom", Sofia, Bulgaria
| | - Esin Koç
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Division of Neonatology, Department of Pediatrics, School of Medicine, Gazi University, Ankara, Turkey
| | - Joana Saldanha
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Pediatrics, Neonatology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Dalia Stoniene
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Neonatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Heili Varendi
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Paediatrics, University of Tartu, Tartu University Hospital, Tartu, Estonia
| | - Giuseppe De Bernardo
- Department of Woman and Child, Ospedale Buon Consiglio Fatebenefratelli, Naples, Italy
| | - John Madar
- Department of Neonatology, University Hospitals Plymouth, Plymouth, UK
| | - Marije Hogeveen
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Luigi Orfeo
- Neonatal Intensive Care Unit, Fatebenefratelli Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Fabio Mosca
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Vertecchi
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
| | - Corrado Moretti
- Union of European Neonatal and Perinatal Societies (UENPS), Milan, Italy
- Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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Pinheiro JMB. Neonatal Airway Management. CHILDREN (BASEL, SWITZERLAND) 2024; 11:82. [PMID: 38255395 PMCID: PMC10814596 DOI: 10.3390/children11010082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024]
Abstract
The neonatal airway is often difficult to secure, whether the practitioner responsible for managing the airway is a neonatologist, pediatrician, anesthesiologist, another specialist or an advanced practice provider [...].
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Affiliation(s)
- Joaquim M B Pinheiro
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA
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Abstract
'Apnoeic oxygenation' describes the diffusion of oxygen across the alveolar-capillary interface in the absence of tidal respiration. Apnoeic oxygenation requires a patent airway, the diffusion of oxygen to the alveoli, and cardiopulmonary circulation. Apnoeic oxygenation has varied applications in adult medicine including facilitating tubeless anaesthesia or improving oxygenation when a difficult airway is known or anticipated. In the paediatric population, apnoeic oxygenation prolongs the time to oxygen desaturation, facilitating intubation. This application has gained attention in neonatal intensive care where intubation remains a challenging procedure. Difficulties are related to the infant's size and decreased respiratory reserve. In addition, policy changes have led to limited opportunities for operators to gain proficiency. Until recently, evidence of benefit of apnoeic oxygenation in the neonatal population came from a small number of infants recruited to paediatric studies. Evidence specific to neonates is emerging and suggests apnoeic oxygenation may increase intubation success and limit physiological instability during the procedure. The best way to deliver oxygen to facilitate apnoeic oxygenation remains an important question.
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Affiliation(s)
- Elizabeth K Baker
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia.
| | - Peter G Davis
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Kate A Hodgson
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia.
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Diggikar S, Krishnegowda R, Nagesh KN, Lakshminrusimha S, Trevisanuto D. Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2023; 108:156-163. [PMID: 36520676 DOI: 10.1136/archdischild-2022-324472] [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: 05/30/2022] [Accepted: 08/05/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess whether laryngeal mask airway (LMA) as compared with face mask (FM) or endotracheal intubation (ETT) is more effective in delivering positive pressure ventilation (PPV) during neonatal resuscitation in low-and-middle income countries (LMICs). STUDY DESIGN We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and searched Medline (PubMed interphase), Cumulative Index of Nursing and Allied Health Literature, Embase and Cochrane Registry between January 1990 and April 2022 for the studies that examined the effect of LMA in delivering PPV compared with the FM or ETT in infants during neonatal resuscitation. We included the studies conducted in LMIC only. We assessed the quality of all the included studies using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) recommendations. RESULTS Our search resulted in eight randomised studies Six studies compared LMA with FM and three studies compared LMA with ETT. When used as the primary device for providing PPV, the LMA as compared with FM resulted in a significant lower failure rate (relative risk (RR) 0.23, 95% CI 0.13 to 0.43) with moderate certainty of evidence (CoE) and lesser need for intubation (RR 0.21, 95% CI 0.07 to 0.58) with low CoE. There was no difference in the incidence of encephalopathy, neonatal admission, need for advanced resuscitations or death. No differences were observed between LMA and ETT. Studies comparing LMA to ETT were limited for any conceivable conclusion. CONCLUSION LMA is more effective than FM in delivering PPV with less failure rates and reduced need for intubation during neonatal resuscitation in term infants and in LMIC without any difference in the incidence of encephalopathy or death. Studies comparing LMA to ETT are scarce with important methodological limitations. PROSPERO REGISTRATION NUMBER CRD42021283478.
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Affiliation(s)
| | | | - Karthik N Nagesh
- Department of Pediatrics, Manipal Hospitals, Bangalore, Karnataka, India
| | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Universita degli Studi di Padova Dipartimento di Salute della Donna e del Bambino, Padova, Italy
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Srinivasan M, Sylvia G, Justin H, Mausma B, Jayasree N, Praveen C, Munmun R. Laryngeal mask ventilation with chest compression during neonatal resuscitation: randomized, non-inferiority trial in lambs. Pediatr Res 2022; 92:671-677. [PMID: 34732813 PMCID: PMC9061897 DOI: 10.1038/s41390-021-01820-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/09/2021] [Accepted: 10/13/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Effective positive-pressure ventilation is a critical factor in newborn resuscitation. Neonatal endotracheal intubation (ETT) needs considerable training and experience, which poses a human factor challenge. Laryngeal mask airway (LMA) ventilation can be a secure and viable alternative during the initial stages of newborn resuscitation. However, there is limited evidence for its use during chest compression (CC). METHODS Seventeen lambs were randomized into LMA or ETT ventilation post cord occlusion induced cardiac arrest. After 5 min of cardiac arrest, resuscitation was initiated as per NRP recommendations. Ventilation, oxygenation, systemic and pulmonary hemodynamic parameters were recorded till the return of spontaneous circulation (ROSC) or 20 min. RESULTS Baseline characteristics were similar between the groups. The incidence of ROSC was 75% (6/8) in the LMA group and 56% (5/9) in the ETT group (p = 0.74). The median (IQR) time to achieve ROSC was 6.85 min (6 min-9.1 min) in the LMA group and 7.50 min (5.33 min-18 min) in the ETT group (p = 0.65). CONCLUSION LMA ventilation during CC is feasible and non-inferior to ETT in this model. IMPACT Laryngeal mask airway (LMA) ventilation with chest compression is feasible and non-inferior to endotracheal tube ventilation in this experimental near-term lamb model of asphyxial cardiac arrest. First translational study to evaluate the use of LMA as an airway device with chest compression. Evidence primer for clinical studies to evaluate and confirm the feasibility and efficacy of LMA ventilation with chest compression are necessary before randomized clinical trials in neonates. LMA use in neonatal cardiopulmonary resusciation (CPR) could have the potential to optimize advanced resuscitation, especially in resource-limited healthcare settings.
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Affiliation(s)
- Mani Srinivasan
- Department of Pediatrics, University at Buffalo, Buffalo, NY, 14203
| | - Gugino Sylvia
- Department of Pediatrics, University at Buffalo, Buffalo, NY, 14203
| | - Helman Justin
- Department of Pediatrics, University at Buffalo, Buffalo, NY, 14203
| | - Bawa Mausma
- Department of Pediatrics, University at Buffalo, Buffalo, NY, 14203
| | - Nair Jayasree
- Department of Pediatrics, University at Buffalo, Buffalo, NY, 14203
| | | | - Rawat Munmun
- Department of Pediatrics, University at Buffalo, Buffalo, NY, 14203
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Boyle E, Roehr CC. Surfactant therapy in late preterm and term neonates with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:393-397. [PMID: 34686533 DOI: 10.1136/archdischild-2021-322890] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are no evidence-based recommendations for surfactant use in late preterm (LPT) and term infants with respiratory distress syndrome (RDS). OBJECTIVE To investigate the safety and efficacy of surfactant in LPT and term infants with RDS. METHODS Systematic review, meta-analysis and evidence grading. INTERVENTIONS Surfactant therapy versus standard of care. MAIN OUTCOME MEASURES Mortality and requirement for invasive mechanical ventilation (IMV). RESULTS Of the 7970 titles and abstracts screened, 17 studies (16 observational studies and 1 randomised controlled trial (RCT)) were included. Of the LPT and term neonates with RDS, 46% (95% CI 40% to 51%) were treated with surfactant. We found moderate certainty of evidence (CoE) from observational studies evaluating infants supported with non-invasive respiratory support (NRS) or IMV that surfactant use may be associated with a decreased risk of mortality (OR 0.45, 95% CI 0.32 to 0.64). Very low CoE from observational trials in which surfactant was administered at FiO2 >0.30-0.40 to infants on Continuous Positive Airway Pressure (CPAP) indicated that surfactant did not decrease the risk of IMV (OR 1.20, 95% CI 0.40 to 3.56). Very low to low CoE from the RCT and observational trials showed that surfactant use was associated with a significant decrease in risk of air leak, persistent pulmonary hypertension of the newborn (PPHN), duration of IMV, NRS and hospital stay. CONCLUSIONS Current evidence base on surfactant therapy in LPT and term infants with RDS indicates a potentially decreased risk of mortality, air leak, PPHN and duration of respiratory support. In view of the low to very low CoE and widely varying thresholds for deciding on surfactant replacement in the included studies, further trials are needed.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, Delhi, India
| | - Elaine Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Charles Christoph Roehr
- Nuffield Department of Population Health, Medical Sciences Division, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK .,Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK.,Faculty of Health Sciences, University of Bristol, Bristol, UK
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