Resuscitation in the Delivery Room: Lung Protection From the First Breath

Wiswell, Thomas E.

doi:10.4187/respcare.01433

Cited by 24 publications

(18 citation statements)

References 46 publications

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“…THE MAJORITY OF EXTREMELY preterm infants require respiratory assistance in the delivery room (41). In part this is because many of these infants do not have the ability to generate the initial prolonged high transpulmonary pressures required to drive lung fluid from the main airways, allow alveolar aeration, establish functional residual capacity (FRC), and then maintain it during tidal ventilation, essential processes for efficient gas exchange and lung protection (19,31).…”

mentioning

confidence: 99%

An individualized approach to sustained inflation duration at birth improves outcomes in newborn preterm lambs

Tingay

Lavizzari

Zonneveld

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

100

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A sustained first inflation (SI) at birth may aid lung liquid clearance and aeration, but the impact of SI duration relative to the volume-response of the lung is poorly understood. We compared three SI strategies: 1) variable duration defined by attaining volume equilibrium using real-time electrical impedance tomography (EIT; SI plat); 2) 30 s beyond equilibrium (SI long); 3) short 30-s SI (SI30); and 4) positive pressure ventilation without SI (no-SI) on spatiotemporal aeration and ventilation (EIT), gas exchange, lung mechanics, and regional early markers of injury in preterm lambs. Fifty-nine fetal-instrumented lambs were ventilated for 60 min after applying the allocated first inflation strategy. At study completion molecular and histological markers of lung injury were analyzed. The time to SI volume equilibrium, and resultant volume, were highly variable; mean (SD) 55 (34) s, coefficient of variability 59%. SI plat and SIlong resulted in better lung mechanics, gas exchange and lower ventilator settings than both no-SI and SI30. At 60 min, alveolar-arterial difference in oxygen was a mean (95% confidence interval) 130 (13, 249) higher in SI30 vs. SIlong group (two-way ANOVA). These differences were due to better spatiotemporal aeration and tidal ventilation, although all groups showed redistribution of aeration towards the nondependent lung by 60 min. Histological lung injury scores mirrored spatiotemporal change in aeration and were greatest in SI 30 group (P Ͻ 0.01, Kruskal-Wallis test). An individualized volume-response approach to SI was effective in optimizing aeration, homogeneous tidal ventilation, and respiratory outcomes, while an inadequate SI duration had no benefit over positive pressure ventilation alone. sustained inflation; neonatal resuscitation; lung mechanics; lung volume; variability; electrical impedance tomography; lung injury THE MAJORITY OF EXTREMELY preterm infants require respiratory assistance in the delivery room (41). In part this is because many of these infants do not have the ability to generate the initial prolonged high transpulmonary pressures required to drive lung fluid from the main airways, allow alveolar aeration, establish functional residual capacity (FRC), and then maintain it during tidal ventilation, essential processes for efficient gas exchange and lung protection (19,31). Recently, applying an initial sustained inflation (SI) at birth, consisting of an elevated pressure applied for longer than needed for usual tidal inflation, followed by sufficient positive end-expiratory pressure (PEEP), has been proposed as a method of generating the initial transpulmonary pressure needed at birth (10,18,20). SI has been extensively investigated in preterm animals (15,26,29,32,33,(35)(36)(37)(38) and humans (10, 18, 34) with conflicting results. Some studies suggested SI improved aeration, FRC, and cerebral oxygen delivery (29,32,33), while others failed to demonstrate any benefit over standard respiratory support with sufficient PEEP (26,(35)(36)(37). SI was associated wi...

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confidence: 99%

An individualized approach to sustained inflation duration at birth improves outcomes in newborn preterm lambs

Tingay

Lavizzari

Zonneveld

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

100

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“…Practices that directly affect mortality and morbidity include antenatal steroids [4], gentle resuscitation at delivery [5], careful oxygen delivery and monitoring [6,7], pain control [8], avoidance of sepsis and hypothermia [9], better nutrition [10] and supportive care [11]. There are many reasons why care may not be adequate in neonatal intensive care units (NICUs) in LMICs including very low nurse-to-infant ratios, inadequate equipment to blend, deliver and monitor oxygen, and the fact that care is often by nurse assistants who have had limited training.…”

Section: Introductionmentioning

confidence: 99%

Educating Neonatal Nurses in Brazil: A Before-and-After Study with Interrupted Time Series Analysis

Gilbert

Darlow

Zin³

et al. 2014

Neonatology

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Background: Preterm birth contributes significantly to infant mortality and morbidity, including blindness from retinopathy of prematurity (ROP). Access to intensive neonatal care is expanding in many countries, but care is not always optimal, one factor being that nursing is often by inadequately trained nurse assistants. Objective: The aim of this study was to evaluate whether an educational package for nurses improves a range of outcomes including survival rates and severe ROP in 5 neonatal units in Rio de Janeiro, Brazil. Methods: The study design included an uncontrolled before-and-after study in 5 units, with interrupted time series analysis. Participatory approaches were used to develop a self-administered educational package for control of pain, oxygenation, infection, nutrition, and temperature and to improve supportive care (‘POINTS of Care'). Educational materials and DVD clips were developed and training skills of nurse tutors were enhanced. There were two 1-year periods of data collection before and after a 3-month period of self-administration of the education package. Results: Overall, 74% of 401 nurses and nurse assistants were trained. A total of 679 and 563 infants were included in the pre- and post-training periods, respectively. Despite improvement in knowledge and nursing practices, such as the delivery and monitoring of oxygen, there was no change in survival (pre-training 80%, post-training 78.2%), severe ROP (1.6 vs. 2.8%), sepsis (11.3 vs. 12.3 cases per 1,000 infant days) or other outcomes. Outcomes worsened over the pre-intervention period but the change to an improvement after the intervention was not statistically significant. During the study period many trained staff left the units, but few were replaced. Conclusions: Future studies need to focus on barriers to implementation, team building, leadership and governance, as well as the acquisition of knowledge and skills.

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“…CPAP is useful for opening the alveoli and distal airways, and to maintain adequate functional residual capacity [5]. However, there is no evidence to support or refute the use of CPAP in the delivery room for term neonates [1].…”

Section: Discussionmentioning

confidence: 99%

“…Oxygen has long been used worldwide in the delivery room [5]. The attitude towards the use of oxygen in the delivery room has changed [6].…”

Section: Discussionmentioning

confidence: 99%

Respiratory Stabilization after Delivery in Term Infants after the Update of the Japan Resuscitation Council Guidelines in 2010

Hishikawa

Fujinaga²,

Fujiwara³

et al. 2016

Neonatology

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Background: The Japan Resuscitation Council (JRC) updated the guidelines for neonatal cardiopulmonary resuscitation in 2010, which recommended appropriate oxygen supplementation under the assessment of oximetry, with continuous positive airway pressure (CPAP) as a consideration in the delivery room. Whether this update has resulted in an improvement of respiratory stabilization in term neonates has not been well investigated to date. Objectives: The aim of this study is to evaluate the impact of the update of the JRC Guidelines in 2010 on the frequency of respiratory support for term neonates within 24 h of life in the nursery or neonatal intensive care unit (NICU). Methods: We conducted a retrospective, single-center study using data of term neonates born between 2008 and 2009 (defined as ‘group 1', before the update of the guidelines), and between 2011 and 2012 (defined as ‘group 2', after the update of the guidelines). We compared resuscitation procedures in the delivery room and respiratory support in the nursery or NICU within 24 h of life between the two groups. Respiratory support included oxygen therapy, nasal CPAP and mechanical ventilation. Results: A total of 5,036 infants were analyzed. In group 2, oxygen administration in the delivery room was significantly decreased (38.9 vs. 22.1%, p < 0.001) and face mask CPAP in the delivery room increased (1.7 vs. 11.1%, p < 0.001). The prevalence of respiratory support within 24 h of life in the nursery or NICU increased significantly in group 2 (group 1, 6.8% vs. group 2, 16.6%, p < 0.001). Conclusions: The update of the JRC Guidelines in 2010 resulted in an increase of respiratory support for term infants within 24 h of life.

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Resuscitation in the Delivery Room: Lung Protection From the First Breath

Cited by 24 publications

References 46 publications

An individualized approach to sustained inflation duration at birth improves outcomes in newborn preterm lambs

An individualized approach to sustained inflation duration at birth improves outcomes in newborn preterm lambs

Educating Neonatal Nurses in Brazil: A Before-and-After Study with Interrupted Time Series Analysis

Respiratory Stabilization after Delivery in Term Infants after the Update of the Japan Resuscitation Council Guidelines in 2010

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