Sustained Lung Inflations During Neonatal Resuscitation at Birth: A Meta-analysis

Abstract

CONTEXT: The International Liaison Committee on Resuscitation prioritized review of sustained inflation (SI) of the lung at birth. OBJECTIVE: To complete a systematic review and meta-analysis comparing strategies using 1 or more SI ≥1 second with intermittent inflations <1 second for newborns at birth. DATA SOURCES: Medline, Embase, and Evidence-Based Medicine Reviews were searched from January 1, 1946, to July 20, 2020. STUDY SELECTION: Studies were selected by pairs of independent reviewers in 2 stages. DATA EXTRACTION: Reviewers extracted data, appraised risk of bias, and assessed certainty of evidence for each outcome. RESULTS: Ten trials enrolling 1502 preterm newborns were included. Five studies included newborns who did not receive assisted ventilation at the outset. There were no differences between SI and control groups for death before discharge or key morbidities. For death within the first 2 days, comparing SI with the controls, risk ratio was 2.42 (95% confidence interval = 1.15–5.09). In subgroup analysis of preterm infants ≤28 + 0 weeks’ gestation, for death before discharge, risk ratio was 1.38 (95% confidence interval = 1.00–1.91). Together, these findings suggest the potential for harm of SI. LIMITATIONS: The certainty of evidence was very low for death in the delivery room and low for all other outcomes. CONCLUSIONS: In this systematic review, we did not find benefit in using 1 or more SI >5 seconds for preterm infants at birth. SI(s) may increase death before discharge among the subgroup born ≤28 + 0 weeks’ gestation. There is insufficient evidence to determine the likely effect of SI(s) on other key morbidities.

Is Chest Compression Superimposed with Sustained Inflation during Cardiopulmonary Resuscitation an Alternative to 3:1 Compression to Ventilation Ratio in Newborn Infants?

“…SI as initial respiratory support in the DR has been postulated to achieve a more unified lung aeration [44]. However, recent systematic reviews reported similar rates of bronchopulmonary dysplasia when SI was compared with intermittent positive pressure ventilation for initial respiratory support in the DR [45,46]. These reviews also reported that in a subgroup of <28 weeks' gestation, SI was associated with potential increased risk of death before discharge (risk ratio 2.42 (95% confidence interval = 1.15-5.09)) and increased risk of death within the first 2 days (risk ratio 1.38 (95% confidence interval = 1.00-1.91)), when compared to intermittent positive pressure ventilation [45,46].…”

“…Recently, the SAIL trial compared SI with intermittent positive pressure ventilation in < 28 weeks' gestation infants and reported an increased mortality within the first 48 h with SI [67]. Most recently, a meta-analysis from ILCOR raised concerns about the potential harm of SI for premature infants < 28 weeks' gestation [46]. These data raise some concerns about the use of SI during the initial respiratory support.…”

Delivery Room Care for Premature Infants Born after Less than 25 Weeks’ Gestation—A Narrative Review

“…The European resuscitation guidelines recommend "five inflations maintaining the inflation pressure for up to 2-3 s" [6], while the North American resuscitation guidelines recommend PPV [5]. Several trials comparing sustained inflations, in which an inflating pressure is held for a prolonged duration greater than 5 s with PPV demonstrated no differences in the primary outcome of death before hospital discharge or secondary outcome parameters [56][57][58]. The SAIL trial, which enrolled 426 infants (23 to 26 weeks' gestation), was terminated early due to a higher rate of death within the first 48 h of life in the sustained inflation group.…”

Singapore Neonatal Resuscitation Guidelines 2021

“…(63)(64)(65)(66)(67)(68)(69) However, a recent systematic review showed no difference in the primary outcome of death before discharge (RR 1.09, 95% CI 0.83-1.43) as well as other pre-specified critical outcomes. (70)(71)(72) A large randomised controlled trial was terminated early owing to increased early death in newborns with gestational age < 29 weeks who were randomised to SLI (RR 2.42, 95% CI 1.15-5.09). (73)…”