Delivery Room Continuous Positive Airway Pressure and Pneumothorax

Incidence and Management of Neonatal Pneumothorax in a 10-Hospital Regional Perinatal Network in Switzerland: A Retrospective Observational Study

OBJECTIVE

 Pneumothorax (PTX) is a potentially life-threatening condition that affects neonates, with an incidence of 0.05 to 2%. Its management includes conservative treatment, chest tube (CT) drainage, and needle aspiration (NA). Aims were to evaluate the incidence of PTX in a 10-hospital perinatal network, its clinical characteristics and risk factors, and to compare the different treatment options.

STUDY DESIGN

 All neonates diagnosed with PTX and hospitalized in the network were included in this retrospective observational trial over a period of 30 months. Primary outcome was the incidence of PTX. Secondary outcomes were the treatment modality, the length of stay (LOS), and the number of chest X-rays.

RESULTS

 Among the 173 neonates included, the overall incidence of PTX was 0.56 per 100 births with a large range among the hospitals (0.12-1.24). Thirty-nine percent of pneumothoraces were treated conservatively, 41% by CT drainage, 13% by NA, and 7% by combined treatment. Failure rate was higher for NA (37%) than for CT drainage (9%). However, the number of X-rays was lower for patients treated by NA, with a median of 6 (interquartile range [IQR] 4-6.25), than by CT drainage, with a median of 9 (IQR 7-12). LOS was shorter for NA than for CT drainage, with a median of 2 (IQR 1-4.25) and 6 days (IQR 3-15), respectively. Complications, including apnea and urinary retention, occurred in 28% of patients managed with CT drainage, whereas none was observed with NA.

CONCLUSION

 High variability of PTX incidence was observed among the hospitals within the network, but these values correspond to the literature. NA showed to reduce the number of X-rays, the LOS, and complications compared with CT drainage, but it carries a high failure rate. This study helped provide a new decisional management algorithm to harmonize and improve PTX treatment within our network.

KEY POINTS

· Neonatal PTX is a frequent pathology with a high incidence requiring urgent management.. · We report a large variability of PTX incidence between different hospitals of the same network.. · Needle aspiration carries higher failure rate, shorter hospital stay duration without complications reported..

The Feasibility and Impact of a Postresuscitation Care Protocol in the Well Baby Nursery

OBJECTIVE

 The objective of this study is to determine if a postresuscitation care (PRC) protocol in the well baby nursery (WBN) would improve identification of infants requiring neonatal intensive care unit (NICU) admission.

STUDY DESIGN

 This is a retrospective and prospective cohort study of a PRC protocol in 765 WBN admissions after delivery room (DR) resuscitation with continuous positive airway pressure and/or positive pressure ventilation.

RESULTS

 After protocol initiation, NICU transfers during the birth hospitalization increased significantly (11.17 vs. 16.08%, p < 0.05). There was no difference in incidence of NICU transfer (5.99 vs. 7.29%, pre-PRC vs. PRC, p = 0.47) during the first 4 hours of life during protocol administration. Respiratory distress was the most common indication for NICU transfer in both cohorts (7.90 vs. 11.81%, p = 0.09, pre-PRC vs. PRC). Noninvasive positive pressure and/or high-flow nasal cannula (5.72 vs. 9.55%, p = 0.06, pre-PRC vs. PRC) were routinely administered in the NICU to transferred infants.

CONCLUSION

 After apparent recovery from DR resuscitation, WBN admissions experience significant risk of complications requiring NICU transfer, supporting Neonatal Resuscitation Program recommendation for enhanced monitoring. In our study, we demonstrated the feasibility of standardized PRC protocol in the WBN. NICU transfers increased after initiation of a PRC protocol; however, further studies are needed to confirm possible benefits of this PRC protocol in improving identification of infants requiring a higher level of care.

KEY POINTS

· A PRC protocol in WBN is feasible and associated with increased NICU transfer.. · Despite initial apparent recovery, delayed presentation of respiratory distress is a frequent morbidity.. · Increased surveillance as recommended by Neonatal Resuscitation Program is indicated in this population..

Pneumothorax in a term newborn

With the advent of surfactant and gentle ventilation, the incidence of neonatal pneumothorax has decreased over the last two decades. Pneumothorax associated with respiratory distress syndrome is more common in preterm infants, but term infants often present with isolated pneumothorax. The use of CPAP or non-invasive respiratory support in the delivery room for a term infant with respiratory distress increases transpulmonary pressures and increases the risk of pneumothorax. Prompt diagnosis with a high index of suspicion, quick evaluation by transillumination, chest X-ray or lung ultrasound is critical. Management includes observation, needle thoracocentesis and if necessary, chest tube placement. This manuscript reviews the incidence, pathogenesis, diagnosis and management of a term infant with isolated pneumothorax, summarizing the combination of established knowledge with new understanding, including data on diagnostic modes such as ultrasound, reviewing preventative measures, and therapeutic interventions such as needle thoracocentesis and a comparison of pigtail vs. straight chest tubes.

Incomplete Exhalation during Resuscitation-Theoretical Review and Examples from Ventilation of Newborn Term Infants

BACKGROUND

Newborn resuscitation guidelines recommend positive pressure ventilation (PPV) for newborns who do not establish effective spontaneous breathing after birth. T-piece resuscitator systems are commonly used in high-resource settings and can additionally provide positive end-expiratory pressure (PEEP). Short expiratory time, high resistance, rapid dynamic changes in lung compliance and large tidal volumes increase the possibility of incomplete exhalation. Previous publications indicate that this may occur during newborn resuscitation. Our aim was to study examples of incomplete exhalations in term newborn resuscitation and discuss these against the theoretical background.

METHODS

Examples of flow and pressure data from respiratory function monitors (RFM) were selected from 129 term newborns who received PPV using a T-piece resuscitator. RFM data were not presented to the user during resuscitation.

RESULTS

Examples of incomplete exhalation with higher-than-set PEEP-levels were present in the recordings with visual correlation to factors affecting time needed to complete exhalation.

CONCLUSIONS

Incomplete exhalation and the relationship to expiratory time constants have been well described theoretically. We documented examples of incomplete exhalations with increased PEEP-levels during resuscitation of term newborns. We conclude that RFM data from resuscitations can be reviewed for this purpose and that incomplete exhalations should be further explored, as the clinical benefit or risk of harm are not known.

Incidence of ultrasonographic signs of pneumothorax in asymptomatic neonates

INTRODUCTION

Pneumothorax in neonates can be life-threatening. In neonates without respiratory distress, spontaneous pneumothorax can also develop under certain conditions.

OBJECTIVES

To determine the incidence of ultrasonographic signs of pneumothorax in asymptomatic neonates using lung ultrasound as the diagnostic tool.

METHODS

This was an observational prospective study conducted at the Basurto University Hospital (Bilbao, Spain) between January 2018 and December 2020. Lung ultrasound was performed during routine examination of asymptomatic neonates admitted to the maternity ward.

RESULTS

Of a total of 204 asymptomatic neonates included in the study, 21 (10.3%) presented ultrasound signs of pneumothorax (Group A), and 183 (89.7%) had a normal lung ultrasound (Group B). Lung ultrasound was performed after a mean of 19 h of life (range 9-34). The presence of A-lines behind the sternum in the anterior transverse plane, at the intermammillary level, was observed in 100% of patients in Group A compared to no cases in Group B (p < 0.0001). The neonates of Group A presented the lung point located in the midclavicular line, indicative of a mild air leak.

CONCLUSIONS

Lung ultrasound allows precise detection of suspected small-sized air leaks that can be detected in asymptomatic neonates. The true incidence of pneumothorax in asymptomatic neonates may be substantially higher than previously described in the literature.

Perinatal risk factors associated with the need for resuscitation in newborns born through meconium-stained amniotic fluid

OBJECTIVE

The Neonatal Life Support 2020 guidelines emphasize that meconium-stained amniotic fluid (MSAF) remains a significant risk factor for a newborn to receive advanced resuscitation, especially if additional risk factors are present at the time of birth. However, these additional perinatal risk factors are not clearly identified. The purpose of this study was to evaluate the importance of additional independent ante- and intrapartum risk factors in the era of no routine endotracheal suctioning that determine the need for resuscitation in newborns born through MSAF.

METHODS

This retrospective cohort study included deliveries ≥ 35 weeks' gestation associated with MSAF that occurred between January 1, 2017 and December 31, 2019. The newborns needing resuscitation (any intervention beyond the initial steps) were compared to those not needing resuscitation. Among newborns needing resuscitation, those needing advanced resuscitation (continuous positive airway pressure/ positive pressure ventilation or beyond) were compared to those not needing advanced resuscitation.

RESULTS

Logistic regression analysis revealed that among various perinatal factors, primigravida, thick meconium, fetal distress, chorioamnionitis, rupture of membranes ≥ 18 hours, post-term (gestational age ≥ 42 weeks), cesarean section or shoulder dystocia independently significantly increased the odds of a meconium-stained newborn needing resuscitation. Among these factors, fetal distress, chorioamnionitis or cesarean section independently further increased the odds of needing advanced resuscitation.

CONCLUSION

Risk stratification of perinatal factors associated with the need for newborn resuscitation and advanced resuscitation in the deliveries associated with MSAF may help neonatal teams and resources to be appropriately prioritized and optimally utilized.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Ventilation devices for neonatal resuscitation at birth: A systematic review and meta-analysis

Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are available: fixed pressure devices (FPD; T-pieces or ventilators) and hand driven pressure devices (HDPD; self- or flow-inflating bags). This systematic review and meta-analysis aims to compare clinical outcomes after neonatal resuscitation according to device type.

METHODS

Four databases were searched from inception to 2022, January. Search strategies included Mesh/Emtree terms as well as free language without any restriction. Randomized, quasi-randomized studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included.

RESULTS

Nine studies recruiting 3621 newborns were included: 5 RCTs, 2 RCTs with interventions bundles and 2 prospective cohorts. Meta-analysis of the 5 RCTs demonstrated significant reductions in bronchopulmonary dysplasia (RR0,68[0,48-0,96]-NNT 31) and other respiratory outcomes: intubation in the delivery room (RR0,72[0,58-0,88]-NNT 13,4), mechanical ventilation requirements (RR0,81[0,67-0,96]-NNT 17) and duration (MD-1,54 days[-3,03- -0,05]), need for surfactant (RR0,79[0,64-0,96]-NNT 7,3). The overall analysis found a lower mortality in the FPD group (OR0,57[0,47-0,69]-NNT 12,7) and confirmed decreases in intubation, surfactant requirement and mechanical ventilation rates (OR 0,56[0,40-0,79]- NNT7,5; OR 0,67[0,55-0,82]-NNT10,7 and OR0,58[0,42-0,80]- NNT 7,4 respectively). The risk of cystic periventricular leukomalacia (cPVL) decreased significantly with FPD (OR0.59[0.41-0.85]-NNT 27). Pneumothorax rates were similar (OR0.82[0.44-1.52]).

CONCLUSION AND RELEVANCE

Resuscitation at birth with FPD improves respiratory transition and decreases BPD with a very low to moderate certainty of evidence. There is suggestion of decreases in mortality and cPVL. Further studies are still needed to confirm those results.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Physiology of neonatal resuscitation: Giant strides with small breaths

The transition of a fetus to a newborn involves a sequence of well-orchestrated physiological events. Most neonates go through this transition without assistance but 5-10% may require varying degrees of resuscitative interventions at birth. The most crucial event during this transition is lung inflation with optimal concentrations of oxygen. Rarely, extensive resuscitation including chest compressions and medication may be required. In the past few decades, significant strides have been made in our understanding of the cardiorespiratory transition at birth from a fetus to a newborn and the subsequent resuscitation. This article reviews the physiology behind neonatal transition at birth and various interventions during neonatal resuscitation.

Outcome of neonatal hypoxemic respiratory failure: a livebirth population-based retrospective survey

Background

To explore the prevalence, outcome and perinatal risks of neonatal hypoxemic respiratory failure (NRF) in a survey of all livebirths from a regional network of perinatal-neonatal care during the transition period after 5-year universal health insurance implemented in China.

Methods

Clinical data of all neonatal respiratory morbidities in Huai’an were retrospectively collected in the regional perinatal network database of all livebirths as vital statistics in 2015. NRF was defined as hypoxemia requiring continuous positive airway pressure (CPAP) and/or mechanical ventilation (MV) for at least 24 h. Mortality risks of antenatal and perinatal morbidities, major respiratory therapies and complications were analyzed by multivariable logistic regression model.

Results

There were 788 NRF cases identified in 9.9% (7960) hospitalized, or 13.3‰ (59056) livebirths, in which 6.7% received intensive care and 93.0% critical care. The major underlying morbidities were respiratory distress syndrome (RDS, 36.4%) and pneumonia/sepsis (35.3%), treated mainly by CPAP, MV and surfactant. Significantly improved outcomes by surfactant in RDS were in patients with birthweight (BW) < 1500 g or gestational age (GA) < 32 weeks. The overall mortality rate in NRF was 18.4% whereas for those of BW < 1000 g and GA < 28 weeks, 70% and 54%, respectively. The multivariable regression analysis showed the highest odds for NRF death among meconium aspiration syndrome, congenital anomalies, BW < 1500 g and necrotizing enterocolitis, whereas born in level III hospitals, cesarean delivery, CPAP and MV were associated with markedly reduced death odds.

Conclusions

The salient findings with associated risk estimates reflected efficiency of respiratory support as critical care in a prefectural regional network infrastructure for annual livebirths in 5.6 million inhabitants. It implicated the representativeness of contemporaneous perinatal-neonatal care standard at medium to medium-high level, in one/fourth of the population of China, aiming at saving more life of very critical and preterm infants for better survival.

Variation and Temporal Trends in Delivery Room Management of Moderate and Late Preterm Infants

BACKGROUND

Although delivery room (DR) intervention decreases with increasing gestational age (GA), little is known about DR management of moderate and late preterm (MLP) infants.

METHODS

Using the Vermont Oxford Network database of all NICU admissions, we examined the receipt of DR interventions including supplemental oxygen, positive pressure ventilation, continuous positive airway pressure, endotracheal tube ventilation, chest compressions, epinephrine, and surfactant among MLP infants (30 to 36 weeks') without congenital anomalies born from 2011 to 2020. Pneumothorax was examined as a potential resuscitation-associated complication. Intervention frequency was assessed at the infant- and hospital-level, stratified by GA and over time.

RESULTS

Overall, 55.3% of 616 110 infants (median GA: 34 weeks) from 483 Vermont Oxford Network centers received any DR intervention. Any DR intervention frequency decreased from 89.7% at 30 weeks to 44.2% at 36 weeks. From 2011 to 2020, there was an increase in the provision of continuous positive airway pressure (17.9% to 47.8%, P ≤.001) and positive pressure ventilation (22.9% to 24.9%, P ≤.001) and a decrease in endotracheal tube ventilation (6.9% to 4.0% P ≤.001), surfactant administration (3.5% to 1.3%, P ≤.001), and pneumothorax (1.9% to 1.6%, P ≤.001). Hospital rates of any DR intervention varied (median 54%, interquartile range 47% to 62%), though the frequency was similar across hospitals with different NICU capabilities after adjustment.

CONCLUSIONS

The DR management of MLP infants varies at the individual- and hospital-level and is changing over time. These findings illustrate the differing interpretation of resuscitation guidelines and emphasize the need to study MLP infants to improve evidence-based DR care.

Delivery Room Respiratory Stabilization of Preterm Neonates: A Randomized, Controlled Trial

OBJECTIVE

To determine whether heated humidified high-flow nasal cannula (HHHFNC) is noninferior to NCPAP to provide DR respiratory support to preterm neonates of gestational age (GA) 28-36 wk.

METHODS

This randomized, controlled, noninferiority trial included 124 spontaneously breathing preterm neonates who developed respiratory distress soon after birth and/or had a FiO₂ requirement > 0.3. Primary outcome measure was treatment failure within 24 h. The absolute risk difference with 95% confidence interval (CI) were calculated with a noninferiority margin of 10%. Secondary outcome variables were temperature at admission, time to treatment failure, treatment failure at 72 h, need for surfactant, intubation, duration of respiratory support, and incidences of adverse events including mortality. Intention-to-treat analysis was done in Stata software.

RESULTS

Both the groups were similar in baseline characteristics. There was no statistically significant difference between the treatment failure rates with HHHFNC (13.1%, n = 61) and NCPAP (11.1%, n = 63) (risk difference 2.0%, 95% CI - 9.9% to 14.07%, p = 0.73). However, noninferiority of HHHFNC to NCPAP could not be conclusively proved as the 95% CI crossed both 0 and the noninferiority margin of 10%. There were no significant differences in secondary outcomes.

CONCLUSIONS

HHHFNC showed similar efficacy and safety as NCPAP irrespective of gestational age, though its noninferiority to NCPAP remained inconclusive.

TRIAL REGISTRATION

Clinical Trial Registry of India, Registration no: CTRI/2019/10/021633, https://ctri.icmr.org.in/.

Association of delayed initiation of non-invasive respiratory support with pulmonary air leakage in outborn late-preterm and term neonates

The frequency of non-invasive respiratory support use has increased in neonates of all gestational ages with respiratory distress (RD). However, the impact of delayed initiation of non-invasive respiratory support in outborn neonates remains poorly understood. This study aimed to identify the impact of the delayed initiation of non-invasive respiratory support in outborn, late-preterm, and term neonates. Medical records of 277 infants (gestational age of ≥ 35 weeks) who received non-invasive respiratory support as primary respiratory therapy < 24 h of age between 2016 and 2020 were retrospectively reviewed. Factors associated with respiratory adverse outcomes were investigated in 190 outborn neonates. Infants with RD were divided into two groups: mild (fraction of inspired oxygen [FiO₂] ≤ 0.3) and moderate-to-severe RD (FiO₂ > 0.3), depending on their initial oxygen requirements from non-invasive respiratory support. The median time for the initiation of non-invasive respiratory support at a tertiary center was 3.5 (2.2-5.0) h. Male sex, a high oxygen requirement (FiO₂ > 0.3), high CO₂ level, and respiratory distress syndrome were significant factors associated with adverse outcomes. Subgroup analysis revealed that in the moderate-to-severe RD group, delayed commencement of non-invasive respiratory support (≥ 3 h) was significantly associated with pulmonary air leakage (p = 0.033).

CONCLUSION

Our study shows that outborn neonates with moderate-to-severe RD, who were treated with delayed non-invasive respiratory support, were associated with an increased likelihood of pulmonary air leakage. Additional prospective studies are required to establish the optimal timing and methods of non-invasive respiratory support for outborn, late-preterm, and term infants.

WHAT IS KNOWN

• Non-invasive respiratory support is widely used in neonates of all gestational ages. • Little is known on the impact of delayed initiation of non-invasive respiratory support in outborn, late preterm, and term neonates.

WHAT IS NEW

• Male sex, high oxygen requirement (FiO2 >0.3), high initial CO2 level, and respiratory distress syndrome significantly correlated with adverse outcomes. • Outborn late-preterm and term neonates with high oxygen requirement who were treated with delayed non-invasive respiratory support indicated an increased likelihood of pulmonary air leakage.

Prevalence of major morbidities and outcome of all hospitalized neonates. A retrospective cohort study of Huai'an neonatal survivals

BACKGROUND

Reliable data for causal implication of neonatal survival in China are lacking. We assumed that by analyzing surviving data of in-hospital neonatal care based on all livebirths in Huai'an, prevalence of neonatal morbidity, mortality and causal relations may be derived comprehensively.

MATERIALS AND METHODS

Data of all regionally hospitalized neonates were retrospectively linked with corresponding whole livebirths (59,056) in 2015 as a cohort. Diagnoses of diseases and causes of deaths were redefined and categorized. Disease patterns, prevalence of morbidities, case-fatality rate (CFR), and cause-specific mortality rate (CSMR) referring to livebirths were presented. Perinatal and disease-specific risks of death were estimated by multivariable logistic regression.

RESULTS

In 7,960 (134.8‰) hospitalized patients, 168 (2.1%) died in hospital (2.85‰ of livebirths). Prevalence of major morbidities were 76.8‰ hyperbilirubinemia, 57.4‰ pneumonia, 32.7‰ intraventricular hemorrhage, 20.7‰ sepsis, 20.2‰ birth asphyxia, 9.69‰ congenital anomalies (CA), and 5.30‰ respiratory distress syndrome (RDS). The CFR (CSMR) of major diseases were 30.4% (0.12‰) meconium aspiration syndrome, 17.6% (0.22‰) necrotizing enterocolitis, 14.1% (0.75‰) RDS, 9.09% (0.88‰) CA, 5.26% (0.07‰) bronchopulmonary dysplasia, 1.71% (0.36‰) sepsis and 1.51% (0.31‰) asphyxia. Overall mortality rates were 4.6% and 6.8% in the preterm and low birthweight, and >50% in those of <28 week gestation or <1000 g birthweight, respectively. Mortality risks associated with the perinatal and neonatal morbidities were markedly declined with variable magnitude by multivariable regression models.

CONCLUSIONS

The in-hospital neonatal survival datafile, depicted as the prevalence of major morbidities and CSMR of livebirth population in Huai'an, denoted overall and specific quality and efficiency of the perinatal-neonatal care system. Its concept and methodology should be relevant, and outcome extrapolated, to other countries or domestic regions, with similar socioeconomic development.

Evaluation of T-piece resuscitator in the delivery room management of pre-term neonates with respiratory distress syndrome in resource-limited settings: A pre-post intervention study

The aim of our study was to evaluate the impact of the T-piece resuscitator in the delivery room management of pre-term neonates in a resource-limited setting. We compared the incidence rates of delivery room intubation, surfactant replacement therapy, pulmonary air leak syndrome, and pre-term very low birth weight infant mortality, before and after T-piece use. Bi-monthly neonatal resuscitation training sessions were conducted for healthcare providers during the study period. We emphasized hands-on experience with the T-piece resuscitator and delivery room early respiratory care practices during the post-intervention epoch. Our pre- and post-intervention data recorded statistically significant decline in delivery room intubations, a 32% decrease in surfactant replacement therapy, and a 57% decrease in air leaks in pre-term neonates. However, the use of T-piece resuscitator did not have a statistically significant effect on pre-term very low birth weight infant mortality.

Neonatal Pneumothorax in Late Preterm and Full-Term Newborns with respiratory Distress: A Single-Center Experience

Purpose: To evaluate the incidence rate, clinical characteristics, and perinatal outcomes of pneumothorax in late preterm and full-term newborns with respiratory distress and analyze the risk factors associated with pneumothorax.Methods: Infants born at ≥34 weeks’ gestation with respiratory distress and pneumothorax admitted between February 2014 and December 2020 were enrolled in this study. The pneumothorax group (n=36) was matched to the control group (n=144) in a 1:4 ratio, based on gestational age and birth weight. Risk factors were identified using logistic regression analysis with backward stepwise selection.Results: The incidence of pneumothorax during the study period was 1.36% (38/2,788). All patients were diagnosed with pneumothorax within 48 hours after birth, and increased oxygen demand was the most common symptom. The proportion of mortality and perinatal morbidity, such as intraventricular hemorrhage ≥grade 3, was significantly higher in the pneumothorax group than in the control group. The risk factors associated with pneumothorax were the need for positive pressure ventilation in the delivery room (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.26 to 9.12; P=0.015) and a higher fraction of inspired oxygen to achieve an oxygen saturation of ≥90% on admission (OR, 1.06; 95% CI, 1.03 to 1.09; P<0.001).Conclusion: Pneumothorax should be suspected in late preterm and full-term newborns with respiratory distress within the first 3 days of life. Based on these risk factors, early diagnosis can reduce perinatal mortality and morbidity.

Decreasing delivery room CPAP-associated pneumothorax at ≥35-week gestational age

OBJECTIVE

We previously reported an increase in pneumothorax after implementing delivery room (DR) continuous positive airway pressure (CPAP) for labored breathing or persistent cyanosis in ≥35-week gestational age (GA) neonates unexposed to DR-positive pressure ventilation (DR-PPV). We hypothesized that pneumothorax would decrease after de-implementing DR-CPAP in those unexposed to DR-PPV or DR-O₂ supplementation (DR-PPV/O₂).

STUDY DESIGN

In a retrospective cohort excluding DR-PPV the primary outcome was DR-CPAP-related pneumothorax (1st chest radiogram, 1st day of life). In a subgroup treated by the resuscitation team and admitted to the NICU, the primary outcome was DR-CPAP-associated pneumothorax (1st radiogram, no prior PPV) without DR-PPV/O₂.

RESULTS

In the full cohort, occurrence of DR-CPAP-related pneumothorax decreased after the intervention (11.0% vs 6.0%, P < 0.001). In the subgroup, occurrence of DR-CPAP-associated pneumothorax decreased after the intervention (1.4% vs. 0.06%, P < 0.001).

CONCLUSION

The occurrence of CPAP-associated pneumothorax decreased after avoiding DR-CPAP in ≥35-week GA neonates without DR-PPV/O₂.

Association of antenatal steroids with surfactant administration in moderate preterm infants born to women with diabetes mellitus and/or hypertension

BACKGROUND

Randomized trials of antenatal steroid administration (ANS) for extreme or moderate preterm pregnancies excluded women with diabetes mellitus (DM) and included few with preeclampsia.

METHODS

Cohort study (n = 1,813) including moderate preterm births [29^0/7-33^6/7wks' gestational age GA)] before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with hypertensive disorders (HTN) and/or DM. We compared surfactant administration in Group-1 (neither HTN nor DM), Group-2a (HTN not DM), Group-2b (DM not HTN) and Group-2c (DM and HTN).

RESULTS

Surfactant administration was less frequent after ANS in Group-1 [adjusted odds ratio (aOR) 0.54, 95% confidence interval (CI) 0.31, 0.93, P = 0.03], Group-2a (aOR 0.36, CI 0.22, 0.58, P < 0.001) and Group-2c (aOR 0.29, CI 0.12, 0.71, P = 0.007) but not Group-2b (P = 0.64).

CONCLUSIONS

ANS administration was independently associated with less surfactant administration in moderately preterm neonates whose mothers had neither HTN nor DM, and those with HTN, but not those with DM without HTN.

Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.

Delivery room CPAP in improving outcomes of preterm neonates in low-and middle-income countries: A systematic review and network meta-analysis

AIM

To study the impact of delivery room continuous positive airway pressure (DRCPAP) on outcomes of preterm neonates in low- and middle- income countries (LMICs) by comparing with interventions: oxygen supplementation, late DRCPAP, DRCPAP with sustained inflation, DRCPAP with surfactant and invasive mechanical ventilation (IMV).

METHODS

Medline, Embase, CENTRAL, WOS and CINAHL searched. Observational studies and randomized controlled trials (RCTs) were included. Pair-wise meta-analysis and Bayesian network meta-analysis (NMA) were utilized. Primary outcome was receipt of IMV.

RESULTS

Data from 11 of the 18 included studies (4 observational studies, 7 RCTs) enrolling 4210 preterm infants was synthesized. Moderate certainty of evidence (CoE) from NMA of RCTs comparing DRCPAP with surfactant administration versus DRCPAP alone suggested no decrease in subsequent receipt of IMV [Risk ratio (RR); 95% Credible Interval (CrI): 0.73; (0.34, 1.40)]. Very low CoE from observational studies comparing use of DRCPAP versus oxygen supplementation indicated a trend towards decreased IMV [RR; 95% Confidence Interval (CI): 0.75; (0.56-1.00)]. Although moderate CoE from NMA evaluating DRCPAP versus oxygen supplementation showed a trend towards decreased receipt of surfactant, it did not reach statistical significance [RR; 95% CrI: 0.69; (0.44, 1.06)]. Moderate CoE from NMA indicated that none of the interventions, when compared with use of supplemental oxygen alone or with each other decreased mortality or bronchopulmonary dysplasia.

LIMITATIONS

CoE was very low for primary outcome.

CONCLUSIONS

Present evidence is not sufficient for use of DRCPAP, but also did not show harm. Since it seems unlikely that there are marked variations in patient physiology to explain the difference in efficacy between high income countries and LMICs, we suggest future research evaluating other barriers in improving the effectiveness of DRCPAP in LMICs.

Effect of continuous positive airway pressure versus nasal cannula on late preterm and term infants with transient tachypnea of the newborn

OBJECTIVE

To compare continuous positive airway pressure (CPAP) with nasal cannula (NC) as primary noninvasive respiratory therapy in hypoxic infants for transient tachypnea of the newborn (TTN).

STUDY DESIGN

Retrospective cohort study of infants born at ≥34 weeks of gestation between January 1, 2015 and December 31, 2018.

RESULT

After adjusting for gestational age and birth weight, the maximum fractional inspired oxygen (FiO2) was significantly lower in the CPAP group with an incidence rate ratio (IRR) of 0.85 (95% CI: 0.76-0.96). Although nonsignificant, the CPAP group needed 32% fewer hours on oxygen with an IRR of 0.68 (95% CI: 0.38-1.22). The duration of respiratory support and the incidence of pneumothorax were similar between both groups.

CONCLUSION

Comparing CPAP with NC as initial noninvasive respiratory therapy for TTN, significantly lower maximum FiO2 was observed in the infants of CPAP group without increase in the incidence of pneumothorax.

What happens to 35 week infants that receive delivery room continuous positive airway pressure?

OBJECTIVE

Delivery room (DR) continuous positive airway pressure (CPAP) is increasing. Our study examined the risk for neonatal morbidities after DR CPAP in 35 week neonates.

STUDY DESIGN

A retrospective study of 259 infants born at 35 weeks gestational age between January 1, 2017-December 31, 2018 at a single center.

RESULTS

DR resuscitation was administered in 30.5%, with 19.7% receiving CPAP alone. Eighty percent who received DR CPAP were admitted to the NICU. DR CPAP was associated with the highest NICU admission risk, 9.3 times the risk of those without DR positive pressure, and with respiratory conditions (RDS: OR 4.22 {CI 1.46-11.51}, TTN: OR 3.30 {CI 1.36-7.64}). For the DR CPAP group, non-invasive positive pressure was administered post resuscitation in 90%.

CONCLUSIONS

In our institution, 35 week infants frequently received DR CPAP. Of these infants, a majority were admitted to the NICU for respiratory disorders.

A birth population-based survey of preterm morbidity and mortality by gestational age

Background

Despite 15–17 millions of annual births in China, there is a paucity of information on prevalence and outcome of preterm birth. We characterized the outcome of preterm births and hospitalized preterm infants by gestational age (GA) in Huai’an in 2015, an emerging prefectural region of China.

Methods

Of 59,245 regional total births, clinical data on 2651 preterm births and 1941 hospitalized preterm neonates were extracted from Huai’an Women and Children’s Hospital (HWCH) and non-HWCH hospitals in 2018–2020. Preterm prevalence, morbidity and mortality rates were characterized and compared by hospital categories and GA spectra. Death risks of preterm births and hospitalized preterm infants in the whole region were analyzed with multivariable Poisson regression.

Results

The prevalence of extreme, very, moderate, late and total preterm of the regional total births were 0.14, 0.53, 0.72, 3.08 and 4.47%, with GA-specific neonatal mortality rates being 44.4, 15.8, 3.7, 1.5 and 4.3%, respectively. There were 1025 (52.8% of whole region) preterm admissions in HWCH, with significantly lower in-hospital death rate of inborn (33 of 802, 4.1%) than out-born (23 of 223, 10.3%) infants. Compared to non-HWCH, three-fold more neonates in HWCH were under critical care with higher death rate, including most extremely preterm infants. Significantly all-death risks were found for the total preterm births in birth weight <  1000 g, GA < 32 weeks, amniotic fluid contamination, Apgar-5 min < 7, and birth defects. For the hospitalized preterm infants, significantly in-hospital death risks were found in out-born of HWCH, GA < 32 weeks, birth weight <  1000 g, Apgar-5 min < 7, birth defects, respiratory distress syndrome, necrotizing enterocolitis and ventilation, whereas born in HWCH, antenatal glucocorticoids, cesarean delivery and surfactant use decreased the death risks.

Conclusions

The integrated data revealed the prevalence, GA-specific morbidity and mortality rate of total preterm births and their hospitalization, demonstrating the efficiency of leading referral center and whole regional perinatal-neonatal network in China. The concept and protocol should be validated in further studies for prevention of preterm birth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03726-4.

Newborn resuscitation devices: The known unknowns and the unknown unknowns

Infant resuscitation devices used at birth must be capable of delivering adequate and consistent ventilation in a controlled and predictable manner to a wide patient weight range, and combinations of transitional lung states. Manual inflation resuscitation devices delivering positive pressure lung inflation at birth can be classified broadly into two types: 1) flow generating, ie silicone self-inflating bags (SIB) also known as bag valve mask (BVM) and 2) flow dependent, ie anaesthetic flow inflating bag (FIB) and t-piece resuscitator (TPR) systems (eg: Neopuff, GE Panda and Draeger Resuscitaires). Globalization, lower production costs, and an expanding market need for devices, has led to a proliferation of brands (both reusable and single use) within a class type. T-piece resuscitators have become the dominant device particularly in high income countries. There remains a paucity of information on the performance characteristics of these devices and their ability to provide the required respiratory parameters for effective and safe ventilation across the full-expected weight range and lung states to which they will be applied. This review aims to inform current clinical practise on the biomechanical efficiency, reliability and efficacy of the most common devices used to apply PPV to newborns and infants ≤10 kgs.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Unilateral neonatal pulmonary interstitial emphysema managed conservatively: A case report

BACKGROUND

Pulmonary interstitial emphysema (PIE) is a pathological state when air escapes from ruptured alveoli and is trapped along the sheaths surrounding the bronchovascular bundle. PIE is not uncommon in infants who require mechanical ventilation and even less common in infants on noninvasive ventilatory support; however, it is extremely unusual in infants in room air.

CASE PRESENTATION

A 2-week-old male infant developed worsening tachypnea in the special-care nursery. The patient was born at 33 weeks' gestation by induced vaginal delivery due to pre-eclampsia. He required positive pressure ventilation at birth and was admitted to the neonatal intensive care unit on nasal continuous positive airway pressure. On the second day of life, exogenous surfactant was administered via endotracheal tube due to increased oxygen requirement, and, soon after, he was weaned off all respiratory support. After 10 days of stability, he developed tachypnea with diminished air entry on the left side of the chest. Chest radiograph and chest computerized tomography confirmed left-sided unilateral PIE. The patient was treated conservatively with positional therapy alone. Significant clinical and radiographic improvement was noticed within 4 days; almost complete resolution by 10 days and the infant was discharged 23 days later. At follow-up at 7 months, the infant was found to be symptom-free with a normal chest radiograph.

CONCLUSIONS

Traditional management of unilateral PIE generally involves a combination of invasive ventilatory support and positional therapy to break the vicious cycle pathophysiology of PIE. This report focuses on the insidious progression of PIE in nonventilated neonates and describes a nontraditional conservative management strategy for the management of unilateral PIE.

In vitro comparison of performance including imposed work of breathing of CPAP systems used in low-resource settings

Respiratory distress due to preterm birth is a significant cause of death in low-resource settings. The introduction of continuous positive airway pressure (CPAP) systems to treat respiratory distress significantly reduced mortality in high-resource settings, but CPAP was only recently introduced in low-resource settings due to cost and infrastructure limitations. We evaluated pressure stability and imposed work of breathing (iWOB) of five CPAP systems used in low resource settings: the Fisher and Paykel bubble CPAP, the Diamedica baby CPAP, the Medijet nCPAP generator, and the first (2015) and second (2017) generation commercially available Pumani CPAPs. Pressure changes due to fresh gas flow were evaluated for each system by examining the relationship between flow and pressure at the patient interface for four pressures generated at the bottle (0, 3, 5, and 7 cm H2O); for the Medijet nCPAP generator, no bottle was used. The slope of the resulting relationship was used to calculate system resistance. Poiseuille's law of resistance was used to investigate significant contributors to resistance. Resistance ranged from 0.05 to 1.40 [Formula: see text]; three CPAP devices had resistances < 0.4 [Formula: see text]: the Fisher and Paykel system, the Diamedica system, and the second generation Pumani bubble CPAP. The other two systems, the Medijet nCPAP generator and the first generation Pumani bCPAP, had resistances >1.0 [Formula: see text]. Imposed WOB was measured using an ASL5000 test lung to simulate the breath cycle for an infant (5.5 kg), a term neonate (4.0 kg), and a preterm neonate (2.5 kg). Imposed WOB ranged from 1.4 to 39.5 mJ/breath across all systems and simulated infant sizes. Changes in pressure generated by fresh gas flow, resistance, and iWOB differ between the five systems evaluated under ideal laboratory conditions. The available literature does not indicate that these differences affect clinical outcomes.

Positive End-Expiratory Pressure in Newborn Resuscitation Around Term: A Randomized Controlled Trial

BACKGROUND

International guidelines for resuscitation recommend using positive end-expiratory pressure (PEEP) during ventilation of preterm newborns. Reliable PEEP-valves for self-inflating bags have been lacking, and effects of PEEP during resuscitation of term newborns are insufficiently studied. The objective was to determine if adding a new PEEP valve to the bag-mask during resuscitation of term and near-term newborns could improve heart rate response.

METHODS

This randomized controlled trial was performed at Haydom Lutheran Hospital in Tanzania (September 2016 to June 2018). Helping Babies Breathe-trained midwives performed newborn resuscitation using self-inflating bags with or without a new, integrated PEEP valve. All live-born newborns who received bag-mask ventilation at birth were eligible. Heart rate response measured by ECG was the primary outcome, and clinical outcome and ventilation data were recorded.

RESULTS

Among 417 included newborns (median birth weight 3200 g), 206 were ventilated without and 211 with PEEP. We found no difference in heart rate response. Median (interquartile range) measured PEEP in the PEEP group was 4.7 (2.0-5.6) millibar. The PEEP group received lower tidal volumes (4.9 [1.9-8.2] vs 6.3 [3.9-10.5] mL/kg; P = .02) and had borderline lower expired CO₂ (2.9 [1.5-4.3] vs 3.3 [1.9-5.0] %; P = .05). Twenty four-hour mortality was 9% in both groups.

CONCLUSIONS

We found no evidence for improved heart rate response during bag-mask ventilation with PEEP compared with no PEEP. The PEEP valve delivered a median PEEP within the intended range. The findings do not support routine use of PEEP during resuscitation of newborns around term.