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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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Hodgson KA, Owen LS, Lui K, Shah V. Neonatal Golden Hour: A survey of Australian and New Zealand Neonatal Network units' early stabilisation practices for very preterm infants. J Paediatr Child Health 2021; 57:990-997. [PMID: 33543835 DOI: 10.1111/jpc.15360] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/25/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023]
Abstract
AIM To identify current 'Golden Hour' practices for initial stabilisation of very preterm infants <32 weeks' gestational age (GA) within tertiary neonatal intensive care units (NICUs) in the Australian and New Zealand Neonatal Network (ANZNN). METHODS A 76-question survey regarding delivery room (DR) and NICU stabilisation practices was distributed electronically to directors of tertiary perinatal NICUs in the ANZNN in January 2019. Responses were categorised into GA subgroups: 23-24, 25-27 and 28-31 weeks' GA. RESULTS The response rate was 100% (24/24 units). Delayed cord clamping (DCC) was practised 'always' or 'often' by 21 units (88%). All units used oximetry to target oxygen saturations, and 23/24 (96%) commenced resuscitation in <40% oxygen. Ten units (42%) routinely used DR electrocardiography monitoring. CPAP was preferred as primary respiratory support in one-third of units for infants born 23-24 weeks' GA, compared with 19 units (79%) at 25-27 weeks' GA and 23 units (96%) at 28-31 weeks' GA. DR skin-to-skin care was uncommon, particularly at lower GAs. Five units (21%) used minimally invasive surfactant therapy for non-intubated infants at 23-24 weeks' GA, 13 units (54%) at 25-27 weeks' GA and 16 units (67%) at 28-31 weeks' GA. CONCLUSIONS Most Golden Hour stabilisation practices align with international guidelines. Consistency exists with respect to DCC, oxygen saturation targeting and primary CPAP use for infants 25 weeks' GA and above. Where evidence is less certain, practices vary across ANZNN NICUs. Time targets for stabilisation measures may help standardise practice for this population.
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Affiliation(s)
- Kate A Hodgson
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Kei Lui
- Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
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Sherman JP, Hedli LC, Kristensen-Cabrera AI, Lipman SS, Schwandt D, Lee HC, Sie L, Halamek LP, Austin NS. Understanding the Heterogeneity of Labor and Delivery Units: Using Design Thinking Methodology to Assess Environmental Factors that Contribute to Safety in Childbirth. Am J Perinatol 2020; 37:638-646. [PMID: 31013540 PMCID: PMC6989398 DOI: 10.1055/s-0039-1685494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE There is limited research exploring the relationship between design and patient safety outcomes, especially in maternal and neonatal care. We employed design thinking methodology to understand how the design of labor and delivery units impacts safety and identified spaces and systems where improvements are needed. STUDY DESIGN Site visits were conducted at 10 labor and delivery units in California. A multidisciplinary team collected data through observations, measurements, and clinician interviews. In parallel, research was conducted regarding current standards and codes for building new hospitals. RESULTS Designs of labor and delivery units are heterogeneous, lacking in consistency regarding environmental factors that may impact safety and outcomes. Building codes do not take into consideration workflow, human factors, and patient and clinician experience. Attitude of hospital staff may contribute to improving safety through design. Three areas in need of improvement and actionable through design emerged: (1) blood availability for hemorrhage management, (2) appropriate space for neonatal resuscitation, and (3) restocking and organization methods of equipment and supplies. CONCLUSION Design thinking could be implemented at various stages of health care facility building projects and during retrofits of existing units. Through this approach, we may be able to improve hospital systems and environmental factors.
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Affiliation(s)
- Jules P. Sherman
- Design Consultant in the Department of Pediatrics and Lecturer of the Stanford d. School, Stanford University, Palo Alto, CA, USA,Jules Sherman, (JS)
| | - Laura C. Hedli
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Steven S. Lipman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA, USA
| | - Doug Schwandt
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA
| | - Henry C. Lee
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA
| | - Lillian Sie
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA
| | - Louis P. Halamek
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA
| | - Naola S. Austin
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA, USA
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Oxygen for respiratory support of moderate and late preterm and term infants at birth: Is air best? Semin Fetal Neonatal Med 2020; 25:101074. [PMID: 31843378 DOI: 10.1016/j.siny.2019.101074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Oxygen has been used for newborn infant resuscitation for more than two centuries. In the last two decades, concerns about oxidative stress and injury have changed this practice. Air (FiO2 0.21) is now preferred as the starting point for respiratory support of infants 34 weeks gestation and above. These recommendations are derived from studies that were conducted on asphyxiated, term infants, recruited more than 10 years ago using strategies that are not commonly used today. The applicability of these recommendations to current practice, is uncertain. In addition, whether initiating respiratory support with air for infants with pulmonary disorders provides sufficient oxygenation is also unclear. This review will address these concerns and provide suggestions for future steps to address knowledge and practice gaps.
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Mechanistic Understanding of High Flow Nasal Cannula Therapy and Pressure Support with an In Vitro Infant Model. Ann Biomed Eng 2019; 48:624-633. [PMID: 31598892 DOI: 10.1007/s10439-019-02377-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
Despite the increased use of high flow nasal cannula therapy, little has been done to predict airway pressures for a full breath cycle. A 3-month-old infant in vitro model was developed, which included the entire upper airway and the first three bifurcations of the lungs. A breathing simulator was used to create a realistic breath pattern, and high flow was provided using a Vapotherm unit. Four cannulas of varying sizes were used to assess the effects of the inner diameter and nasal occlusion of the cannulas on airway pressures. At 8 L min-1, end expiratory pressures of 0.821-1.306 cm H2O and 0.828-1.133 cm H2O were produced in the nasopharynx and trachea, respectively. Correlations were developed to predict full breath cycle airway pressures, based on the gas flow rate delivered, cannula dimensions, as well as the breathing flow rate, for the nasopharynx and trachea. Pearson correlation coefficients for the nasopharynx and trachea correlations were 0.991 and 0.992, respectively. The developed correlations could be used to determine the flow rate necessary for a cannula to produce pressures similar to CPAP settings. The proposed correlations accurately predict the regional airway pressure up to and including 7 cm H2O of support for the entire breath cycle.
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Spillane NT, Chivily C, Andrews T. Short term outcomes in term and late preterm neonates admitted to the well-baby nursery after resuscitation in the delivery room. J Perinatol 2019; 39:983-989. [PMID: 31101848 DOI: 10.1038/s41372-019-0396-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the risk for deterioration in well-baby nursery (WBN) admissions after resuscitation. STUDY DESIGN A single center retrospective study (2015-2016) of 370 resuscitated WBN admissions. RESULTS Of the 11,307 admissions, 3.27% received resuscitation with 183 receiving continuous positive airway pressure (CPAP) alone and 187 receiving positive pressure ventilation (PPV) ± CPAP. Resuscitated neonates were more frequently transferred to the NICU (11.6 versus 3.9%, p < 0.001) compared to those without resuscitation. More neonates requiring CPAP alone were transferred to the NICU compared to those requiring PPV ± CPAP (15.85 versus 7.49%, p = 0.01). Univariate risk ratios for transfer were elevated for CPAP alone and lower gestational age categories. Multivariate regression analyses demonstrated increased transfer risk across gestational age categories only. CONCLUSIONS Neonates admitted to the WBN after delivery room resuscitation are at increased risk for NICU transfer compared to those without resuscitation. This study supports the recommendation for post-resuscitation care.
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Affiliation(s)
- Nicole T Spillane
- Department of Pediatrics, Assistant Professor of Pediatrics at Hackensack Meridian School of Medicine at Seton Hall University, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA.
| | | | - Tracy Andrews
- Department of Research, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA
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Kitsommart R, Nakornchai K, Yangthara B, Jiraprasertwong R, Paes B. Positive end-expiratory pressure during resuscitation at birth in very-low birth weight infants: A randomized-controlled pilot trial. Pediatr Neonatol 2018; 59:448-454. [PMID: 29289490 DOI: 10.1016/j.pedneo.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 09/16/2017] [Accepted: 12/06/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There is limited evidence of the effect of positive end-expiratory pressure (PEEP) during resuscitation soon after birth. Premature neonates may experience respiratory distress from surfactant insufficiency and providing PEEP after the very first breath, may improve outcomes following appropriate resuscitation. The objective of this study was to evaluate the short term respiratory outcomes after positive pressure ventilation (PPV) with PEEP in preterm infants at birth. METHODS A prospective randomized-controlled, pilot trial was conducted. Premature neonates ≤ 32 weeks gestational age or birth weight < 1500 g were recruited. Subjects were allocated to either PEEP of 5 cm H2O (PEEP-5) or no PEEP (PEEP-0) if PPV was administered. Pre-ductal, peripheral capillary oxygen saturation (SpO2) and fraction of inspired oxygen concentration (FiO2) were monitored at 1, 3, 5, 10, 15, and 20 min after birth. FiO2 was adjusted to achieve targeted SpO2 using the 2010 neonatal resuscitation protocol guidelines. RESULTS 56% (14/25; PEEP-0) and 50% (13/26; PEEP-5) infants received PPV. Mean gestational age was 30 (PEEP-0) vs 31 (PEEP-5) weeks. The mean [SD] birthweight (g) of PEEP-0 was significantly lower than PEEP-5 (1050.4 [262.7] vs 1218.8 [236.8], p = 0.02). Pre-ductal SpO2, FiO2 delivered at each time point, and rates of pneumothorax, surfactant administration and oxygen dependency at 36 weeks postmenstrual age or death was similar. CONCLUSION Due to the small sample size and potential bias accrued through random allocation of higher birthweight infants to the PEEP-5 group, the results did not confirm differences in outcomes between the groups, despite evidence favoring postnatal ventilation with PEEP. A further randomized, controlled clinical trial with a larger sample size is warranted to determine the utility and safety of PEEP during the resuscitation of premature infants immediately after birth.
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Affiliation(s)
- Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Kittaya Nakornchai
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Buranee Yangthara
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ratchada Jiraprasertwong
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Schmölzer GM, Roehr CCC. WITHDRAWN: Techniques to ascertain correct endotracheal tube placement in neonates. Cochrane Database Syst Rev 2018; 7:CD010221. [PMID: 29975802 PMCID: PMC6513417 DOI: 10.1002/14651858.cd010221.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. OBJECTIVES To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. SELECTION CRITERIA We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. MAIN RESULTS We did not identify any studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
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Affiliation(s)
- Georg M Schmölzer
- University of AlbertaDepartment of Pediatrics, Division of NeonatologyRoyal Alexandra Hospital, Rm. 418 CSC, 10240 Kingsway AveEdmontonABCanadaT5H 3V9
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Shah V, Hodgson K, Seshia M, Dunn M, Schmölzer GM. Golden hour management practices for infants <32 weeks gestational age in Canada. Paediatr Child Health 2018; 23:e70-e76. [PMID: 30038535 PMCID: PMC6007305 DOI: 10.1093/pch/pxx175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine 'Golden Hour' resuscitation and stabilization practices for infants <32 weeks gestational age in Canadian neonatal intensive care units (NICUs). METHODS A survey was distributed to investigators of the Evidence-based Practice for Improving Quality study within the Canadian Neonatal Network in June 2014. The questionnaire was designed to obtain information on antenatal counselling, resuscitation environment, resuscitation and management practices, including respiratory and nutritional practices in the first hour of life. Responses to these categories were stratified into gestational age groupings: 230/7-236/7, 240/7-256/7, 260/7-276/7 and 280/7-316/7 weeks. Findings were summarized using descriptive statistics. RESULTS Investigators from 14 of the 23 (61%) NICUs responded. Antenatal counselling was provided to >75% of expectant parents by Staff Neonatologists and Neonatal Fellows. Most NICUs (78%) provided resuscitation in a room adjacent to the high-risk delivery room or the NICU, while few (36%) resuscitated in the delivery room only. Twelve (86%) NICUs practiced delayed cord clamping while two practiced milking of the cord (14%) and 100% used thermal wrap for infants <28 weeks' gestation. All, with the exception of three NICUs used fraction of inspired oxygen ≤0.3 for initial resuscitation and 12/14 (86%) centres applied continuous positive airway pressure for spontaneously breathing infants <256/7 weeks' gestation. CONCLUSIONS Participating Canadian NICUs reported that they generally follow Neonatal Resuscitation Program recommendations for stabilization of preterm infants; however, considerable variation exists in the application of evidence-based interventions. Our findings can be used to inform quality improvement initiatives to improve clinical outcomes for this vulnerable population.
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Affiliation(s)
- Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Kate Hodgson
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario
| | - Mary Seshia
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba
| | - Michael Dunn
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
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Maheshwari R, Tracy M, Hinder M, Wright A. Neopuff T-piece resuscitator mask ventilation: Does mask leak vary with different peak inspiratory pressures in a manikin model? J Paediatr Child Health 2017; 53:761-765. [PMID: 28675548 DOI: 10.1111/jpc.13609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 01/12/2017] [Accepted: 04/28/2017] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to compare mask leak with three different peak inspiratory pressure (PIP) settings during T-piece resuscitator (TPR; Neopuff) mask ventilation on a neonatal manikin model. METHODS Participants were neonatal unit staff members. They were instructed to provide mask ventilation with a TPR with three PIP settings (20, 30, 40 cm H2 O) chosen in a random order. Each episode was for 2 min with 2-min rest period. Flow rate and positive end-expiratory pressure (PEEP) were kept constant. Airway pressure, inspiratory and expiratory tidal volumes, mask leak, respiratory rate and inspiratory time were recorded. Repeated measures analysis of variance was used for statistical analysis. RESULTS A total of 12 749 inflations delivered by 40 participants were analysed. There were no statistically significant differences (P > 0.05) in the mask leak with the three PIP settings. No statistically significant differences were seen in respiratory rate and inspiratory time with the three PIP settings. There was a significant rise in PEEP as the PIP increased. Failure to achieve the desired PIP was observed especially at the higher settings. CONCLUSIONS In a neonatal manikin model, the mask leak does not vary as a function of the PIP when the flow rate is constant. With a fixed rate and inspiratory time, there seems to be a rise in PEEP with increasing PIP.
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Affiliation(s)
- Rajesh Maheshwari
- Department of Neonatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Tracy
- Department of Neonatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Murray Hinder
- Department of Neonatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Audrey Wright
- Department of Neonatology, Westmead Hospital, Sydney, New South Wales, Australia
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Tracy M, Maheshwari R, Shah D, Hinder M. Can Ambu self-inflating bag and Neopuff infant resuscitator provide adequate and safe manual inflations for infants up to 10 kg weight? Arch Dis Child Fetal Neonatal Ed 2017; 102:F333-F338. [PMID: 28011794 DOI: 10.1136/archdischild-2016-311830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/24/2016] [Accepted: 11/30/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Manual resuscitation devices for infants and newborns must be able to provide adequate ventilation in a safe and consistent manner across a wide range of patient sizes (0.5-10 kg) and differing clinical states. There are little comparative data assessing biomechanical performance of common infant manual resuscitation devices across the manufacturers' recommended operating weight ranges. We aimed to compare performance of the Ambu self-inflating bag (SIB) with the Neopuff T-piece resuscitator in three resuscitation models. METHODS Five experienced clinicians delivered targeted ventilation to three lung models differing in compliance, delivery pressures and inflation rates; Preterm (0.5 mL/cmH2O, 25/5 cmH2O, 60 per minute), Term (3 mL/cmH2O, 30/5 cmH2O, 40 per minute) and Infant (9 mL/cmH2O, 35/5 cmH2O, 30 per minute). The Neopuff was examined with three gas inflow rates (5 litres per minute (LPM), 10 LPM and 15 LPM) and the Ambu with no gas inflow. RESULTS 3309 inflations were collected and analysed with analysis of variance for repeated measures. The Neopuff was unable to reach set peak inflation pressures and exhibited seriously elevated positive end expiratory pressure (PEEP) with all inflow gas rates (p<0.001) in this infant model. The Ambu SIB accurately delivered targeted pressures in all three models. CONCLUSIONS The Ambu SIB was able to accurately deliver targeted pressures across all three models from preterm to infant. The Neopuff infant resuscitator was unable to deliver the targeted pressures in the infant model developing clinically significant levels of inadvertent PEEP which may pose risk during infant resuscitation.
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Affiliation(s)
- Mark Tracy
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Paediatrics and Child Health, Sydney University, Westmead, New South Wales, Australia
| | - Rajesh Maheshwari
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney University, Sydney, New South Wales, Australia
| | - Dharmesh Shah
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney University, Sydney, New South Wales, Australia
| | - Murray Hinder
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney University, Sydney, New South Wales, Australia
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Shivananda S, Gupta S, Thomas S, Babb L, Meyer CL, Symington A, Paes B, Suresh GK. Impact of a dedicated neonatal stabilization room and process changes on stabilization time. J Perinatol 2017; 37:162-167. [PMID: 27831550 DOI: 10.1038/jp.2016.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 06/03/2016] [Accepted: 10/06/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Our objective was to evaluate the impact of a dedicated resuscitation and stabilization (RAS) room and process changes on infant stabilization time. STUDY DESIGN A prospective quality improvement study was conducted on preterm infants in a tertiary care center. A dedicated RAS room, preresuscitation huddle, infant-isolette-ventilator pairing and improved documentation were implemented. The primary outcome was median time to stabilization and secondary outcomes were illness severity on day 1 and morbidity at discharge. RESULTS A sustained reduction in median time to stabilization from 90 min in the preimplementation phase to 72 min in the sustainability phase was observed. All planned and iterative process changes were integrated into the RAS team's daily routine. Time to completion of procedures decreased, illness severity and morbidity remained unchanged. CONCLUSION A dedicated RAS room adjacent to the delivery suite in conjunction with process changes improves efficiency of care.
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Affiliation(s)
- S Shivananda
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - S Gupta
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - S Thomas
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - L Babb
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - C-L Meyer
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - A Symington
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - B Paes
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - G K Suresh
- Department of Pediatric Medicine, Section of Neonatology, Houston, TX, USA
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Quality improvement project: implementing guidelines supporting noninvasive respiratory management for premature infants. Neonatal Netw 2016; 33:245-53. [PMID: 25161132 DOI: 10.1891/0730-0832.33.5.245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Based on research evidence, the purpose was to implement noninvasive approaches in the initial respiratory stabilization of preterm infants. DESIGN Quality improvement project. SAMPLE One hundred fourteen infants admitted to the neonatal intensive care nursery (NICN) from January 1, 2012 to May 31, 2012 served as a historical control group. Ninety-four infants admitted from January 1, 2013 to May 31, 2013 served as the intervention group. RESULTS After implementation of the quality improvement initiative, there was a statistically significant increase in the rate of using continuous positive airway pressure (CPAP ) by 65.3 percent for initial respiratory stabilization of preterm infants.
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Solevåg AL, Haemmerle E, van Os S, Bach KP, Cheung PY, Schmölzer GM. Comparison of positive pressure ventilation devices in a newborn manikin. J Matern Fetal Neonatal Med 2016; 30:595-599. [DOI: 10.1080/14767058.2016.1180360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Iriondo M, Izquierdo M, Salguero E, Aguayo J, Vento M, Thió M. Encuesta española de reanimación neonatal 5 años después. ¿Vamos mejorando? An Pediatr (Barc) 2016; 84:260-70. [DOI: 10.1016/j.anpedi.2015.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 08/04/2015] [Accepted: 08/14/2015] [Indexed: 10/22/2022] Open
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Assessment of endotracheal tube placement in newborn infants: a randomized controlled trial. J Perinatol 2016; 36:370-5. [PMID: 26765556 DOI: 10.1038/jp.2015.208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 10/15/2015] [Accepted: 11/23/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE International resuscitation guidelines recommend clinical assessment and exhaled CO2 to confirm tube placement immediately after intubation. However, exhaled CO2 devices can display false negative results. In comparison, any respiratory function monitor can be used to measure and display gas flow in and out of an endotracheal tube. However, neither method has been examined in detail. We hypothesized that a flow sensor would improve the assessment of tracheal vs esophageal tube placement in neonates with a higher success rate and a shorter time to tube placement confirmation when compared with the use of a quantitative end-tidal CO2 (ETCO2) detector. STUDY DESIGN Between December 2013 and September 2014, preterm and term infants requiring endotracheal intubation were eligible for inclusion and randomly allocated to either ETCO2 ('ETCO2 group') or flow sensor ('flow sensor group'). All infants were analyzed according to their group at randomization (that is, analysis was by intention-to-treat). RESULT During the study period, a total of 110 infants (n=55 for each group) were randomized. Successful endotracheal tube placements were correctly identified in 100% of cases by the flow sensor compared with 72% of cases with the ETCO2 detector within 10 inflations (P<0.05). The median (interquartile range) number of inflations needed to identify successful tube placement was significantly lower in the flow sensor group with 2 (1 to 3) inflations vs 8 (6 to 10) inflations with the ETCO2 detector (P<0.001). CONCLUSION A flow sensor would improve the assessment of successful endotracheal tube placement with a higher success rate and a shorter time compared with an ETCO2 detector.
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Iriondo M, Izquierdo M, Salguero E, Aguayo J, Vento M, Thió M. Five years after the Spanish neonatal resuscitation survey. Are we improving? ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Terrin G, Conte F, Scipione A, Aleandri V, Di Chiara M, Bacchio E, Messina F, De Curtis M. New architectural design of delivery room reduces morbidity in preterm neonates: a prospective cohort study. BMC Pregnancy Childbirth 2016; 16:63. [PMID: 27008185 PMCID: PMC4804574 DOI: 10.1186/s12884-016-0849-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 03/16/2016] [Indexed: 11/10/2022] Open
Abstract
Background A multidisciplinary committee composed of a panel of experts, including a member of the American Academy of Pediatrics and American Institute of Architects, has suggested that the delivery room (DR) and the neonatal intensive care units (NICU) room should be directly interconnected. We aimed to investigate the impact of the architectural design of the DR and the NICU on neonatal outcome. Methods Two cohorts of preterm neonates born at < 32 weeks of gestational age, consecutively observed during 2 years, were compared prospectively before (Cohort 1: “conventional DR”) and after architectural renovation of the DR realized in accordance with specific standards (Cohort 2: “new concept of DR”). In Cohort 1, neonates were initially cared for a conventional resuscitation area, situated in the DR, and then transferred to the NICU, located on a separate floor of the same hospital. In Cohort 2 neonates were assisted at birth directly in the NICU room, which was directly connected to the DR via a pass-through door. The primary outcome of the study was morbidity, defined by the proportion of neonates with at least one complication of prematurity (i.e., late-onset sepsis, patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, retinopathy of prematurity and necrotizing enterocolitis). Secondary outcomes were mortality and duration of hospitalization. Statistical analysis was performed using standard methods by SPSS software. Results We enrolled 106 neonates (56 in Cohort 1 and 50 in Cohort 2). The main clinical and demographic characteristics of the 2cohorts were similar. Moderate hypothermia (body temperature ≤ 35.9 ° C) was more frequent in Cohort 1 (57 %) compared with Cohort 2 (24 %, p = 0.001). Morbidity was increased in Cohort 1 (73 %) compared with Cohort 2 (44 %, p = 0.002). No statistically significant differences in mortality and median duration of hospitalization were observed between the 2 cohorts of the study. Conclusions If realized according to the proposed architectural standards, renovation of DR and NICU may represent an opportunity to reduce morbidity in preterm neonates.
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Affiliation(s)
- Gianluca Terrin
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Francesca Conte
- Department of Pediatrics, "Sapienza" University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Antonella Scipione
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Vincenzo Aleandri
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.,Research Center on Evaluation of Quality in Medicine - CEQUAM, "Sapienza" University of Rome, Rome, Italy
| | - Maria Di Chiara
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Erica Bacchio
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Messina
- Department of Perinatal Medicine, Evangelical Hospital "V. Betania", Via Argine 604, Naples, 80147, Italy
| | - Mario De Curtis
- Department of Pediatrics, "Sapienza" University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
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Solevåg AL, Haemmerle E, van Os S, Bach KP, Cheung PY, Schmölzer GM. A Novel Prototype Neonatal Resuscitator That Controls Tidal Volume and Ventilation Rate: A Comparative Study of Mask Ventilation in a Newborn Manikin. Front Pediatr 2016; 4:129. [PMID: 27965949 PMCID: PMC5124572 DOI: 10.3389/fped.2016.00129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/14/2016] [Indexed: 11/23/2022] Open
Abstract
The objective of this randomized controlled manikin trial was to examine tidal volume (VT) delivery and ventilation rate during mask positive pressure ventilation (PPV) with five different devices, including a volume-controlled prototype Next Step™ device for neonatal resuscitation. We hypothesized that VT and rate would be closest to target with the Next Step™. Twenty-five Neonatal Resuscitation Program providers provided mask PPV to a newborn manikin (simulated weight 1 kg) in a randomized order with a self-inflating bag (SIB), a disposable T-piece, a non-disposable T-piece, a stand-alone resuscitation system T-piece, and the Next Step™. All T-pieces used a peak inflation pressure of 20 cmH2O and a positive end-expiratory pressure of 5 cmH2O. The participants were instructed to deliver a 5 mL/kg VT (rate 40-60/min) for 1 min with each device and each of three test lungs with increasing compliance of 0.5, 1.0, and 2.0 mL/cmH2O. VT and ventilation rate were compared between devices and compliance levels (linear mixed model). All devices, except the Next Step™ delivered a too high VT, up to sixfold the target at the 2.0-mL/cmH2O compliance. The Next Step™ VT was 26% lower than the target in the low compliance. The ventilation rate was within target with the Next Step™ and SIB, and slightly lower with the T-pieces. In conclusion, routinely used newborn resuscitators over delivered VT, whereas the Next Step™ under delivered in the low compliant test lung. The SIB had higher VT and rate than the T-pieces. More research is needed on volume-controlled delivery room ventilation.
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Affiliation(s)
- Anne Lee Solevåg
- 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; Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Enrico Haemmerle
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology , Auckland , New Zealand
| | - Sylvia van Os
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital , Edmonton, AB , Canada
| | - Katinka P Bach
- Newborn Services, Auckland City Hospital , Auckland , New Zealand
| | - Po-Yin Cheung
- 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
| | - 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
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Pierro M, Ciralli F, Colnaghi M, Vanzati M, Mercadante D, Consonni D, Mosca F. Oxygen administration at birth in preterm infants: a retrospective analysis. J Matern Fetal Neonatal Med 2015; 29:2675-80. [PMID: 26515655 DOI: 10.3109/14767058.2015.1100161] [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: 11/13/2022]
Abstract
OBJECTIVE The aim of the study was to retrospectively investigate the association between initial oxygen concentration in delivery room and short-term outcomes in preterm infants. METHODS Data from infants needing neonatal resuscitation, born at our department between January 2008 and December 2011, were analyzed. Patients were divided into three groups based on gestational age: between 32 and 36 weeks, between 31 and 28 weeks, and below 28 weeks. RESULTS The administration of each additional unit of oxygen up to 50% showed an association with a 5% increased need for mechanical ventilation (MV) in the neonatal intensive care unit in infants between 32 and 36 weeks [adjusted odds ratio 1.1, 95% confidence interval (CI) 1.04-1.1] and infants between 28 and 31 weeks (adjusted odds ratio 1.12, 95% CI 1.08-1.44). On the contrary, in infants below 28 weeks, increasing initial concentration of supplementary oxygen did not show any association with MV. CONCLUSIONS Initial oxygen concentration seems to be associated with increased MV in the NICU. Our observations further stress the need for randomized controlled studies in order to obtain definitive recommendations for the optimal initial oxygen concentration during neonatal resuscitation of preterm infants.
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Affiliation(s)
- Maria Pierro
- a NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano , Milan , Italy and
| | - Fabrizio Ciralli
- a NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano , Milan , Italy and
| | - Mariarosa Colnaghi
- a NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano , Milan , Italy and
| | - Mara Vanzati
- a NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano , Milan , Italy and
| | - Domenica Mercadante
- a NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano , Milan , Italy and
| | - Dario Consonni
- b Epidemiology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico , Milan , Italy
| | - Fabio Mosca
- a NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano , Milan , Italy and
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Hosono S, Tamura M, Kunikata T, Wada M, Kusakawa I, Ibara S. Survey of delivery room resuscitation practices at tertiary perinatal centers in Japan. Pediatr Int 2015; 57:258-62. [PMID: 25208847 DOI: 10.1111/ped.12496] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/25/2014] [Accepted: 08/20/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to determine the current neonatal resuscitation practices for term infants in Japan, immediately before the 2010 publication of the international neonatal resuscitation consensus. METHODS In January 2010, a 26-question survey was mailed to neonatal department directors. RESULTS A total of 287 neonatal departments were identified. Four surveys were returned as undeliverable. A total of 191 surveys were returned completed, but four departments had no labor and delivery rooms (66.6% response rate, 65.2% survey available response rate). Flow-inflating bags were most commonly used (63.2%), followed by self-inflating bags (35.8%), and T-piece resuscitators (1.0%). Among the participants, 42.1% used oxygen blenders, 56.2% used pure oxygen for initial resuscitation, and 79.5% used a pulse oximeter to change the fraction of inspired oxygen. Among the participants, 45.3% used carbon dioxide detectors to confirm intubation, 42.5% routinely used the detectors, and 55.2% used them when confirming a difficult intubation. In addition, 42.5% of the participants used continuous positive airway pressure to treat breathing problems, most commonly with flow-inflating bags (93.2%). CONCLUSIONS The equipment and techniques used in Japanese perinatal center delivery room resuscitation practices are highly varied. Further research is required to determine which devices and techniques are appropriate for this important and common intervention.
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Affiliation(s)
- Shigeharu Hosono
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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Abstract
BACKGROUND The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. OBJECTIVES To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. SELECTION CRITERIA We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. MAIN RESULTS We did not identify any studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
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Affiliation(s)
- Georg M Schmölzer
- Department of Pediatrics, Division of Neonatology, University of Alberta, Royal Alexandra Hospital, Rm. 418 CSC, 10240 Kingsway Ave, Edmonton, AB, Canada, T5H 3V9
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Changes over time in delivery room management of extremely low birth weight infants in Italy. Resuscitation 2014; 85:1072-6. [DOI: 10.1016/j.resuscitation.2014.04.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/26/2014] [Indexed: 11/18/2022]
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Szyld E, Aguilar A, Musante GA, Vain N, Prudent L, Fabres J, Carlo WA. Comparison of devices for newborn ventilation in the delivery room. J Pediatr 2014; 165:234-239.e3. [PMID: 24690329 DOI: 10.1016/j.jpeds.2014.02.035] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 02/03/2014] [Accepted: 02/18/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of a T-piece resuscitator compared with a self-inflating bag for providing mask ventilation to newborns at birth. STUDY DESIGN Newborns at ≥26 weeks gestational age receiving positive-pressure ventilation at birth were included in this multicenter cluster-randomized 2-period crossover trial. Positive-pressure ventilation was provided with either a self-inflating bag (self-inflating bag group) with or without a positive end-expiratory pressure valve or a T-piece with a positive end-expiratory pressure valve (T-piece group). Delivery room management followed American Academy of Pediatrics and International Liaison Committee on Resuscitation guidelines. The primary outcome was the proportion of newborns with heart rate (HR)≥100 bpm at 2 minutes after birth. RESULTS A total of 1027 newborns were included. There was no statistically significant difference in the incidence of HR≥100 bpm at 2 minutes after birth between the T-piece and self-inflating bag groups: 94% (479 of 511) and 90% (466 of 516), respectively (OR, 0.65; 95% CI, 0.41-1.05; P=.08). A total of 86 newborns (17%) in the T-piece group and 134 newborns (26%) in the self-inflating bag group were intubated in the delivery room (OR, 0.58; 95% CI, 0.4-0.8; P=.002). The mean±SD maximum positive inspiratory pressure was 26±2 cm H2O in the T-piece group vs 28±5 cm H2O in the self-inflating bag group (P<.001). Air leaks, use of drugs/chest compressions, mortality, and days on mechanical ventilation did not differ significantly between groups. CONCLUSION There was no difference between the T-piece resuscitator and a self-inflating bag in achieving an HR of ≥100 bpm at 2 minutes in newborns≥26 weeks gestational age resuscitated at birth. However, use of the T-piece decreased the intubation rate and the maximum pressures applied.
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Affiliation(s)
- Edgardo Szyld
- Research Department, FUNDASAMIN, Fundación para la Salud Materno Infantil, Buenos Aires, Argentina.
| | - Adriana Aguilar
- Research Department, FUNDASAMIN, Fundación para la Salud Materno Infantil, Buenos Aires, Argentina; Masters Program in Clinical Trials, Universidad Abierta Interamericana, Buenos Aires, Argentina
| | - Gabriel A Musante
- Research Department, FUNDASAMIN, Fundación para la Salud Materno Infantil, Buenos Aires, Argentina; Department of Pediatrics, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina
| | - Nestor Vain
- Research Department, FUNDASAMIN, Fundación para la Salud Materno Infantil, Buenos Aires, Argentina
| | - Luis Prudent
- Research Department, FUNDASAMIN, Fundación para la Salud Materno Infantil, Buenos Aires, Argentina
| | - Jorge Fabres
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Thio M, Dawson JA, Moss TJ, Galinsky R, Rafferty A, Hooper SB, Davis PG. Self-inflating bags versus T-piece resuscitator to deliver sustained inflations in a preterm lamb model. Arch Dis Child Fetal Neonatal Ed 2014; 99:F274-7. [PMID: 24646620 DOI: 10.1136/archdischild-2013-305239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE In neonatal resuscitation, the use of a sustained inflation (SI) may facilitate lung aeration. Previous studies comparing different resuscitation devices have shown that one model of self-inflating bag (SIB) could not deliver an SI. We aimed to compare the delivery of an SI using four SIBs with that of a T-piece. STUDY DESIGN In intubated preterm lambs, we compared four models of SIB fitted with a positive end expiratory pressure (PEEP) valve to a T-piece using a gas flow of 8 L/min. Four operators aimed to deliver three SIs of 20 cm H₂O for 30 s. The study was repeated with the PEEP valve removed and again with no flow. We measured duration of SI, average inflation pressure (IP) and analysed the shape of the pressure curves. RESULTS 204 combinations were analysed. Mean (SD) duration of SI was Ambu 6(2)s, Laerdal 14(8)s, Parker Healthcare 5(1)s, Mayo Healthcare 33(2)s and T-piece 33(1)s. Mean (SD) average IP was Ambu 17(3)cm H₂O, Laerdal 17(3)cm H₂O, Parker Healthcare 12(5)cm H₂O, Mayo Healthcare 21(2)cm H₂O and T-piece 20(0)cm H₂O. Duration of SI and average IP was significantly different between SIBs (all p<0.001). The findings were substantially unchanged when PEEP valve and flow were removed (all p>0.05). Only the Mayo system delivered SIs with duration and average IP not significantly different from the T-piece (p>0.05). CONCLUSIONS The performance of the four SIBs tested varied considerably. Some are able to deliver an SI even in the absence of gas flow. This may be useful in a resource-limited setting with no gas supply.
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Grubb MR, Carpenter J, Crowe JA, Teoh J, Marlow N, Ward C, Mann C, Sharkey D, Hayes-Gill BR. Forehead reflectance photoplethysmography to monitor heart rate: preliminary results from neonatal patients. Physiol Meas 2014; 35:881-93. [PMID: 24742972 DOI: 10.1088/0967-3334/35/5/881] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Around 5%-10% of newborn babies require some form of resuscitation at birth and heart rate (HR) is the best guide of efficacy. We report the development and first trial of a device that continuously monitors neonatal HR, with a view to deployment in the delivery room to guide newborn resuscitation. The device uses forehead reflectance photoplethysmography (PPG) with modulated light and lock-in detection. Forehead fixation has numerous advantages including ease of sensor placement, whilst perfusion at the forehead is better maintained in comparison to the extremities. Green light (525 nm) was used, in preference to the more usual red or infrared wavelengths, to optimize the amplitude of the pulsatile signal. Experimental results are presented showing simultaneous PPG and electrocardiogram (ECG) HRs from babies (n = 77), gestational age 26-42 weeks, on a neonatal intensive care unit. In babies ⩾32 weeks gestation, the median reliability was 97.7% at ±10 bpm and the limits of agreement (LOA) between PPG and ECG were +8.39 bpm and -8.39 bpm. In babies <32 weeks gestation, the median reliability was 94.8% at ±10 bpm and the LOA were +11.53 bpm and -12.01 bpm. Clinical evaluation during newborn deliveries is now underway.
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Affiliation(s)
- M R Grubb
- Electrical Systems and Optics Research Division, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK
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Pinheiro JMB, Furdon SA, Boynton S, Dugan R, Reu-Donlon C, Jensen S. Decreasing hypothermia during delivery room stabilization of preterm neonates. Pediatrics 2014; 133:e218-26. [PMID: 24344110 DOI: 10.1542/peds.2013-1293] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Hypothermia during delivery room stabilization of very low birth weight (VLBW) newborns is independently associated with mortality, yet it occurred frequently both in collaborative networks and at our institution. We aimed to attain admission temperatures in the target range of 36 °C to 38 °C in ≥ 90% of inborn VLBW neonates through implementation of a thermoregulation bundle. METHODS This quality improvement project extended over 60 consecutive months, using sequential plan-do-check-act cycles. During the 14 baseline months, we standardized temperature measurements and developed the Operation Toasty Tot thermoregulation bundle (including consistent head and torso wrapping with plastic, warmed blankets, and a closed stabilization room). We introduced this bundle in month 15 and added servo-controlled, battery-powered radiant warmers for stabilization and transfer in month 21. We provided results and feedback to staff throughout, using simple graphics and control charts. RESULTS There were 164 inborn VLBW babies before and 477 after bundle implementation. Introduction and optimization of the bundle decreased the incidence of hypothermia, with rates remaining in the target range for the last 13 study months. The incidence of temperatures >38 °C was ~ 2% both before and after bundle implementation. CONCLUSIONS This thermoregulation bundle resulted in sustained improvement in normothermia rates during delivery room stabilization of VLBW newborns. Our benchmark goal of ≥ 90% admission temperatures above 36 °C was met without increasing hyperthermia rates. Because these results compare favorably with those of recently published research or improvement collaboratives, we aim to maintain our performance through routine surveillance of admission temperatures.
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Affiliation(s)
- Joaquim M B Pinheiro
- Department of Pediatrics/Neonatology, Albany Medical Center MC-101, 47 New Scotland Ave., Albany, NY 12208.
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Nicoll J, O‘Reilly M, LaBossiere J, Lee T, Cowan S, Bigam D, Cheung P, Schmölzer G. Effect of cardiac output changes on exhaled carbon dioxide in newborn piglets. Resuscitation 2013; 84:1439-42. [DOI: 10.1016/j.resuscitation.2013.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 05/05/2013] [Accepted: 05/07/2013] [Indexed: 11/25/2022]
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Effect of flow rate, humidifier dome and water volume on maximising heated, humidified gas use for neonatal resuscitation. Resuscitation 2013; 84:1428-32. [DOI: 10.1016/j.resuscitation.2013.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 04/05/2013] [Accepted: 04/06/2013] [Indexed: 11/20/2022]
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Marked variation in delivery room management in very preterm infants. Resuscitation 2013; 84:1558-61. [PMID: 23948446 PMCID: PMC3828483 DOI: 10.1016/j.resuscitation.2013.06.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/04/2013] [Accepted: 06/23/2013] [Indexed: 11/23/2022]
Abstract
Background The International Liaison Committee on Resuscitation (ILCOR) and UK Resuscitation Council (UKRC) updated guidance on newborn resuscitation in late 2010. Objectives To describe delivery room (DR) practice in stabilisation following very preterm birth (<32 weeks gestation) in the UK. Methods We emailed a national survey of current DR stabilisation practice of very preterm infants to all UK delivery units and conducted telephone follow-up calls. Results We obtained 197 responses from 199 units (99%) and complete data from 186 units. Tertiary units administered surfactant in the DR (93% vs. 78%, P = 0.01), instituted DR CPAP (77% vs. 50%, P = 0.0007), provided PEEP in the delivery room (91% vs. 69%, P = 0.0008), and started resuscitation in air or blended oxygen (91% vs. 78%, P = 0.04) more often than non-tertiary units. Routine out of hours consultant attendance at very preterm birth was more common in tertiary units (82% vs. 55%, P = 0.0005). Conclusions Marked variation in DR stabilisation practice of very preterm infants persisted one year after the publication of revised UKRC guidance. Delivery room care provided in non-tertiary units was less consistent with current international guidance.
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Sasi A, Chandrakumar N, Deorari A, Paul VK, Shankar J, Sreenivas V, Agarwal R. Neonatal self-inflating bags: achieving titrated oxygen delivery using low flows: an experimental study. J Paediatr Child Health 2013; 49:671-7. [PMID: 23819690 DOI: 10.1111/jpc.12269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 11/28/2022]
Abstract
AIM To determine delivered O2 concentration (dFiO2) during manual inflations using neonatal self-inflating resuscitation bags (SIBs) at oxygen (O2) flow rates <1 L/min. METHODS This experimental study, determined dFiO2 during 216 sets of manual inflations at different O2 flow rate (L/min; 0.2, 0.4, 0.6, 0.8, 1.0 and 5.0), controlling peak inspiratory pressures (PIP; cm of H2O; 10-15, 15-20 and 20-25), inflation rates (per min; 30, 40 and 60), with and without O2 reservoir using two SIBs--the Laerdal infant resuscitator (240 mL) and Ambu Mark IV resuscitator (300 mL). A leak proof circuit connecting the SIB in series with pressure transducer, O2 analyzer and test lung was used. All possible combinations were tested four times each. The dFiO2 with each possible combination was compared using generalised estimating equation. RESULTS The mean dFiO2 with SIB even without reservoirs varied with rates and PIP from 75 to 93% at O2 flow rate of 5 L/min. At 1 L/min flow itself, 65-85% O2 is delivered. The dFiO2 was reduced to approximately 40% with flow of 0.2 L/min, PIP 20-25 cmH2O and inflations 40-60 per min. CONCLUSION During manual breaths using neonatal SIBs, the delivered O2 concentration of nearly 40% is attained at clinically used inflation pressures and rates by using lower flows. A graded increase in O2 delivery from 40 to 99% was obtained with flow varying from 0.2 to 5 L/min and addition of reservoir. However, even at such low flows, reduction in O2 concentration below 40% was unattained.
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Affiliation(s)
- Arun Sasi
- Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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The delivery room of the future: the fetal and neonatal resuscitation and transition suite. Clin Perinatol 2012; 39:931-9. [PMID: 23164188 DOI: 10.1016/j.clp.2012.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite advances in the understanding of fetal and neonatal physiology and the technology to monitor and treat premature and full-term neonates, little has changed in resuscitation rooms. The authors' vision for the Fetal and Neonatal Resuscitation and Transition Suite of the future is marked by improvements in the amount of physical space, monitoring technologies, portable diagnostic and therapeutic technologies, communication systems, and capabilities and training of the resuscitation team. Human factors analysis will play an important role in the design and testing of the improvements for safe, effective, and efficient resuscitation of the newborn.
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Schmölzer GM, O'Reilly M, Davis PG, Cheung PY, Roehr CC. Confirmation of correct tracheal tube placement in newborn infants. Resuscitation 2012; 84:731-7. [PMID: 23211476 DOI: 10.1016/j.resuscitation.2012.11.028] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 11/26/2012] [Accepted: 11/26/2012] [Indexed: 11/29/2022]
Abstract
Tracheal intubation remains a common procedure during neonatal intensive care. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes. The current gold standard test to confirm tube position is a chest radiograph, however this is often delayed until after ventilation has commenced. Hence, point of care methods to confirm correct tube placement have been developed. The aim of this article is to review the available literature on tube placement in newborn infants. We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms "Infant, Newborn", "Endotracheal intubation", "Resuscitation", "Clinical signs", "Radiography", "Respiratory Function Tests", "Laryngoscopy", "Ultrasonography", and "Bronchoscopy". Various techniques have been studied to help clinicians assess tube placement. However, despite 85 years of clinical practice, the search for higher success rates and quicker intubation continues. Currently, chest radiography remains the gold standard test to confirm tube position. However, rigorous evaluation of new techniques is required to ensure the safety of newborn infants.
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Abstract
Although significant advances in respiratory care have been made in neonatal medicine, bronchopulmonary dysplasia (BPD) remains the most common serious pulmonary morbidity in premature infants. The development of BPD is the result of the complex interactions between multiple perinatal and postnatal factors. Early identification of infants at the most risk of developing BPD through the use of estimators and models may allow a targeted approach at reducing BPD in the future.
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Affiliation(s)
- Andrea Trembath
- Rainbow Babies & Children's Hospital, 11000 Euclid Avenue, RBC Suite 3100, Cleveland, OH 44106, USA.
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Hawkes CP, Ryan CA, Dempsey EM. Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: A qualitative review. Resuscitation 2012; 83:797-802. [DOI: 10.1016/j.resuscitation.2011.12.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 10/14/2022]
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Delivery room resuscitation of preterm infants in Canada: current practice and views of neonatologists at level III centers. J Perinatol 2012; 32:491-7. [PMID: 21941233 DOI: 10.1038/jp.2011.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To explore physicians' experiences and views related to resuscitation practice of preterm infants at birth, and determine whether the Canadian modifications of 2006 Neonatal Resuscitation Program (NRP) guidelines have been accepted by neonatologists. STUDY DESIGN Neonatologists (n=146) at 25 tertiary neonatal intensive care units (NICUs) across Canada were contacted via email to participate in a web-based survey about their practice regarding resuscitation of preterm infants in the delivery room (DR). RESULT In all, 78 respondents (53%) from 23 centres completed the survey. Participants reported significant variability in temperature control measures. Hypothermia, <36.5 °C on NICU admission, was reported by 49% of respondents. Room air is used by 59% of respondents to initiate resuscitation. The majority (91%) of participants use pulse oximetry to titrate oxygen administration. Although more than two thirds (69%) of respondents target an oxygen saturation range of 85 to 92%, 51% of respondents would allow 5 to 10 min for the oxygen saturation to reach the target level. Carbon dioxide detectors are commonly used to confirm endotracheal tube placement (90%). Although respondents (96%) agree on the use of positive end- expiratory pressure (PEEP), when providing positive pressure ventilation (PPV), only 60% would initiate PPV with a pre-set peak inspiratory pressure, mostly 20 cm H(2)O. CONCLUSION DR resuscitation practices are highly variable in Canadian NICU's and the currently recommended NRP guidelines are not uniformly followed. Factors leading to variability and discordance in practice should be investigated to facilitate better compliance.
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Cordaro T, Gibbons Phalen A, Zukowsky K. Hypothermia and Occlusive Skin Wrap in the Low Birth Weight Premature Infant: An Evidentiary Review. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.nainr.2012.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
PURPOSE OF REVIEW There has been a substantial increase in the number of studies of neonatal resuscitation and it is timely to review the accumulating evidence. RECENT FINDINGS There have been major changes in the way that newly born infants are managed in the delivery room. Colour is no longer recommended as a useful indicator of oxygenation or effectiveness of resuscitation. Pulse oximetry provides rapid, continuous and accurate information on both oxygenation and heart rate. Resuscitation of term infants should begin with air, with the provision of blended oxygen to maintain oxygen saturations similar to those of term infants requiring no resuscitation. Positive end-expiratory pressure during initial ventilation aids lung aeration and establishment of functional residual capacity. Respiratory function monitoring allows operators to identify factors adversely affecting ventilation, including leak around the face mask and airway obstruction. Clamping of the umbilical cord should be delayed for at least 1 min for infants not requiring resuscitation. SUMMARY The International Liaison Committee on Resuscitation guidelines on the management of newborn infants were updated in 2010 and incorporate much of the newly available evidence. The use of intensive care techniques in the delivery room is promising but requires further evaluation. Monitoring techniques and interventions need to be adapted for use in developing countries.
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Sensing and responding to compliance changes during manual ventilation using a lung model: can we teach healthcare providers to improve? J Pediatr 2012; 160:372-376.e1. [PMID: 22048042 DOI: 10.1016/j.jpeds.2011.09.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/19/2011] [Accepted: 09/19/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the hypothesis that an educational intervention would improve the resuscitator's ability to provide on-target volume ventilation during pulmonary compliance changes. STUDY DESIGN Neonatal professionals (n = 27) ventilated an electromechanical lung model simulating a 3-kg baby while targeting a tidal volume of 4-6 mL/kg. In this preintervention and postintervention study, a one-on-one educational intervention aimed to improve the primary outcome of on-target tidal volume delivery during high and low compliance. Seventeen subjects were retested 8 months later. RESULTS When only pressure was displayed, and using a self-inflating bag, participants improved from a mean of 6% of breaths on-target to 21% immediately after education (P < .01). Using a flow-inflating bag, participants improved from 1% to 7% of breaths on-target (P < .01). Eight-month retention testing demonstrated no difference compared with baseline. With volume displayed, the mean baseline success rate was 84% with the self-inflating bag and 68% with the flow-inflating bag. There was no significant change after education or at 8-month follow-up. CONCLUSION When pressure is displayed, resuscitators can improve their ability to respond to changes in compliance after an educational intervention. When volume is displayed, performance is markedly better at baseline, but not improved after the intervention. Our findings reconfirm that resuscitation bags should have volume displays.
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Marked variation in newborn resuscitation practice: a national survey in the UK. Resuscitation 2012; 83:607-11. [PMID: 22245743 PMCID: PMC3350052 DOI: 10.1016/j.resuscitation.2012.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 12/09/2011] [Accepted: 01/05/2012] [Indexed: 11/24/2022]
Abstract
Background Although international newborn resuscitation guidance has been in force for some time, there are no UK data on current newborn resuscitation practices. Objective Establish delivery room (DR) resuscitation practices in the UK, and identify any differences between neonatal intensive care units (NICU), and other local neonatal services. Methods We conducted a structured two-stage survey of DR management, among UK neonatal units during 2009–2010 (n = 192). Differences between NICU services (tertiary level) and other local neonatal services (non-tertiary) were analysed using Fisher's exact and Student's t-tests. Results There was an 89% response rate (n = 171). More tertiary NICUs institute DR CPAP than non-tertiary units (43% vs. 16%, P = 0.0001) though there was no significant difference in frequency of elective intubation and surfactant administration for preterm babies. More tertiary units commence DR resuscitation in air (62% vs. 29%, P < 0.0001) and fewer in 100% oxygen (11% vs. 41%, P < 0.0001). Resuscitation of preterm babies in particular, commences with air in 56% of tertiary units. Significantly more tertiary units use DR pulse oximeters (58% vs. 29%, P < 0.01) and titrate oxygen based on saturations. Almost all services use occlusive wrapping to maintain temperature for preterm infants. Conclusions In the UK, there are many areas of good evidence based DR practice. However, there is marked variation in management, including between units of different designation, suggesting a need to review practice to fulfil new resuscitation guidance, which will have training and resource implications.
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Hartung JC, te Pas AB, Fischer H, Schmalisch G, Roehr CC. Leak during manual neonatal ventilation and its effect on the delivered pressures and volumes: an in vitro study. Neonatology 2012; 102:190-5. [PMID: 22796898 DOI: 10.1159/000339325] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 05/08/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mask leak is a frequent problem during manual ventilation. Our aim was to investigate the effect of predefined leaks on delivered peak inflation pressure (PIP), positive end-expiratory pressure (PEEP) and tidal volume (V(t)) when using different neonatal manual ventilation devices. METHODS A neonatal-lung model was ventilated at different respiratory rates (RRs, 40, 60, 80/min) using a mechanically operated self-inflating bag (SIB) and a manually operated T-piece resuscitator (PIP = 20 cm H(2)O, PEEP = 5 cm H(2)O). Four open tubes of different lengths, which produced up to 90% leak, were consecutively attached between the ventilation device and the lung model. A pneumotachograph was used to measure pressures, flow and volume. RESULTS With increasing leak (0-90%) PIP and PEEP decreased significantly (p < 0.001) for both devices. Using the SIB, the mean ± SD PIP fell from 20.1 ± 0.3 to 15.9 ± 7 cm H(2)O and PEEP fell from 5.0 ± 0 to 0.3 ± 0.5 cm H(2)O, leading to an increased pressure difference (Δp); V(t) increased from 8.8 ± 0.7 to 11.1 ± 0.8 ml (p < 0.001). With increasing RRs, the leak-dependent changes were significantly lower (p < 0.001). Using the T-piece resuscitator, PIP dropped independent of RRs from 20.3 ± 0.5 to 18.5 ± 0.6 cm H(2)O and PEEP from 5.1 ± 0.4 to 4.0 ± 0 cm H(2)O, while Δp and V(t) did not differ significantly. CONCLUSION The decrease in PIP and PEEP with increasing leak is RR dependent and distinctly higher when using an SIB compared to a T-piece device. In contrast to V(t) delivered with the SIB, V(t) delivered by the T-piece resuscitator was nearly constant even for leaks up to 90%.
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Affiliation(s)
- J C Hartung
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
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Dawson JA, Gerber A, Kamlin COF, Davis PG, Morley CJ. Providing PEEP during neonatal resuscitation: which device is best? J Paediatr Child Health 2011; 47:698-703. [PMID: 21449898 DOI: 10.1111/j.1440-1754.2011.02036.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The study aims to compare three commonly used neonatal resuscitation devices, the Laerdal self-inflating bag with a positive end expiratory pressure (PEEP) valve, a T-piece resuscitator (T-piece) and a flow-inflating bag to provide peak inflation pressure (PIP) and PEEP. METHODS Participants were asked to use each device to give positive pressure ventilation to a modified neonatal mannequin via a face mask to achieve 40-60 inflations per minute, aiming for a PIP/PEEP of 30/5 cm H₂O. A manometer was visible to participants with each device. PIP, PEEP, percentage leak at the face mask and expired tidal volume were measured using a hot-wire anemometer. We analysed 20 inflations from each participant for each device. RESULTS Fifty participants provided PIP and PEEP with each device. The T-piece was the most accurate and consistent. The flow-inflating bag had the most variation. The leak was lowest with the self-inflating bag and PEEP and highest with the flow-inflating bag, but all had wide variation. CONCLUSION Each device was able to provide PIP and PEEP when used appropriately. When compared with other resuscitation devices, the T-piece provided the most accurate and consistent PIP and PEEP.
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Mawson IE, Dawson JA, Donath SM, Davis PG. A comparison of oxygen saturation measurements obtained from a 'blue sensor' with a standard sensor. J Paediatr Child Health 2011; 47:693-7. [PMID: 21449897 DOI: 10.1111/j.1440-1754.2011.02035.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] [Indexed: 11/30/2022]
Abstract
AIM The study aims to investigate pulse oximetry measurements from a 'blue' pulse oximeter sensor against measurements from a 'standard' pulse oximeter sensor in newly born infants. METHODS Immediately after birth, both sensors were attached to the infant, one to each foot. SpO₂ measurements were recorded simultaneously from each sensor for 10 min. Agreement between pairs of SpO₂ measurements were calculated using Bland-Altman analysis. RESULTS Thirty-one infants were studied. There was good correlation between simultaneous SpO₂ measurements from both sensors (r² = 0.75). However, the mean difference between 'blue' and 'standard' sensors was -1.6%, with wide 95% limits of agreement +18.4 to -21.6%. The range of mean difference between sensors from each infant ranged from -20 to +20. CONCLUSION The mean difference between the blue and standard sensor SpO₂ measurements is not clinically important.
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Schmölzer G, Resch B, Schwindt JC. Standards zur Versorgung von reifen Neugeborenen in Österreich. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2472-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Shearman AD, Hou D, Dunster KR, Jardine L. Heating of gases during neonatal resuscitation: a bench study. Resuscitation 2011; 83:369-73. [PMID: 21958926 DOI: 10.1016/j.resuscitation.2011.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 07/11/2011] [Accepted: 08/22/2011] [Indexed: 11/16/2022]
Abstract
AIM Standard practice within the neonatal unit is to use heated humidified gas as it decreases respiratory complications in neonates requiring respiratory support. Using cold unhumidified gases during resuscitation could potentially cool the baby as well as exacerbate potential lung injury. We aimed to study the temperature and humidity aspects of using heated, humidified gas for neonatal resuscitation. METHODS A heated patient circuit was connected to a T-piece resuscitator via a humidifier. An oxygen flowmeter was set at 10 L/min. Temperature recordings at the humidifier chamber (T1), distal temperature probe (T2) and T-piece (T3) were taken over 20 min at 30s intervals. A humidity sensor was placed at T3. RESULTS Target temperatures were not reached. Time to 36°C (mean (sd)): T1 11.1 min (1.71); T3 11.6 min (1.77). T2 took 13.6 min (1.07) to reach 39°C. T1 and T3 were within ±1°C at 5.1 min (0.6). A biphasic relationship demonstrated the time lag between the temperatures of the heated patient circuit and the humidifier chamber. T3 strongly correlated to T1 when T1 is ≥28°C (r(2)=0.85). Humidity was difficult to measure and results were inferred from temperature recordings. CONCLUSION This in vitro test showed that heated, humidified gas is possible during neonatal resuscitation. Adequate time must be allowed for the humidifier chamber to warm to near optimal temperature. The patient circuit is initially heated faster than the humidifier chamber. The displayed T1 temperature correlates to the temperature at T3 at ≥28°C.
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Affiliation(s)
- Andrew D Shearman
- Department of Newborn Services, Mater Mothers' Hospital, South Brisbane, Australia.
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Vohra S, Reilly M. Equipoise with respect to wrapping premature newborns immediately after delivery. Paediatr Child Health 2011; 11:270. [PMID: 19030286 DOI: 10.1093/pch/11.5.270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sunita Vohra
- Associate Professor of Pediatrics, University of Alberta, Edmonton, Alberta Co-PI, VON HeLP trial
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Schilleman K, Schmölzer GM, Kamlin OC, Morley CJ, te Pas AB, Davis PG. Changing gas flow during neonatal resuscitation: A manikin study. Resuscitation 2011; 82:920-4. [DOI: 10.1016/j.resuscitation.2011.02.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 02/10/2011] [Accepted: 02/14/2011] [Indexed: 11/15/2022]
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Abstract
The hemodynamic evaluation and monitoring in the critically ill newborn (particularly the premature infant) poses unique challenges because of urgency, size limitations, and the persistence of fetal shunt channels. Echocardiography and other noninvasive methods are currently the mainstay of hemodynamic assessment. Evaluation of the hemodynamic significance of the arterial duct in the premature infant and cardiac performance in the near-term and term newborn with asphyxia, shock, and persistent pulmonary hypertension need to be more carefully refined, particularly assessments of left ventricular diastolic dysfunction. There is a need for evaluating a number of assessments as targets of goal-directed therapy in the unstable newborn infant. We provide an interpretation of the evidence supporting various monitoring strategies.
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Dawson JA, Schmölzer GM, Kamlin COF, Te Pas AB, O'Donnell CPF, Donath SM, Davis PG, Morley CJ. Oxygenation with T-piece versus self-inflating bag for ventilation of extremely preterm infants at birth: a randomized controlled trial. J Pediatr 2011; 158:912-918.e1-2. [PMID: 21238983 DOI: 10.1016/j.jpeds.2010.12.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 10/15/2010] [Accepted: 12/02/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate whether infants < 29 weeks gestation who receive positive pressure ventilation (PPV) immediately after birth with a T-piece have higher oxygen saturation (SpO₂) measurements at 5 minutes than infants ventilated with a self inflating bag (SIB). STUDY DESIGN Randomized, controlled trial of T-piece or SIB ventilation in which SpO₂ was recorded immediately after birth from the right hand/wrist with a Masimo Radical pulse oximeter, set at 2-second averaging and maximum sensitivity. All resuscitations started with air. RESULTS Forty-one infants received PPV with a T-piece and 39 infants received PPV with a SIB. At 5 minutes after birth, there was no significant difference between the median (interquartile range) SpO₂ in the T-piece and SIB groups (61% [13% to 72%] versus 55% [42% to 67%]; P = .27). More infants in the T-piece group received oxygen during delivery room resuscitation (41 [100%] versus 35 [90%], P = .04). There was no difference in the groups in the use of continuous positive airway pressure, endotracheal intubation, or administration of surfactant in the delivery room. CONCLUSION There was no significant difference in SpO₂ at 5 minutes after birth in infants < 29 weeks gestation given PPV with a T-piece or a SIB as used in this study.
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