Time to lung aeration during a sustained inflation at birth is influenced by gestation in lambs

McCall, Karen; Waldmann, Andreas D.; Pereira‐Fantini, Prue M.; Oakley, Regina; Miedema, Martijn; Perkins, Elizabeth; Davis, Peter G; Dargaville, Peter A.; Böhm, Stephan H.; Dellacà, Raffaele L.; Sourial, Magdy; Zannin, Emanuela; Rajapaksa, Anushi; Tan, Audrey; Adler, Andy; Frerichs, Inéz; Tingay, David G.

doi:10.1038/pr.2017.141

Cited by 25 publications

(87 citation statements)

References 41 publications

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“…Although their baseline characteristics did not differ from the 2016 population, they were excluded from the final analysis. For the remaining infants, the not significant but expected increased median maximal SI duration and PEEP level in the lower GA-based subgroup [17], confirms the understanding by the medical team of the individualized stepwise LR maneuvers. In a hindsight, to improve the adherence, more than 6 months should have been probably dedicated to educate the medical team and/or a video recording and reviewing program implemented.…”

Section: Discussionsupporting

confidence: 67%

Feasibility of combining two individualized lung recruitment maneuvers at birth for very low gestational age infants: a retrospective cohort study

Kanaan

Bloch-Queyrat²,

Boubaya³

et al. 2020

BMC Pediatr

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Background: Lung recruitment at birth has been advocated as an effective method of improving the respiratory transition at birth. Sustained inflations (SI) and dynamic positive end-expiratory pressure (PEEP) were assessed in clinical and animal studies to define the optimal level. Our working hypothesis was that very low gestational age infants (VLGAI) < 32 weeks' gestation require an individualized lung recruitment based on combining both manoeuvers. Methods: Between 2014 and 2016, 91 and 72 inborn VLGAI, requiring a respiratory support beyond a continuous positive airway pressure (CPAP) = 5 cmH2O, were enrolled before and after introducing these manoeuvers based on progressive increase in SI up to 15 s, with simultaneous gradual increase in PEEP up to 15 cmH2O, according to the cardiorespiratory response. Retrospective comparisons of the incidence of mechanical ventilation (MV) < 72 h of life, short-term and before discharge morbidity were then performed.Results: Among extremely low gestational age infants (ELGAI) < 29 weeks' gestation, the following outcomes decreased significantly: intubation (90 to 55%) and surfactant administration (54 to 12%) in the delivery room, MV (92 to 71%) and its mean duration < 72 h of life (45 h to 13 h), administration of a 2nd dose of surfactant (35 to 12%) and postnatal corticosteroids (52 to 19%), and the rate of bronchopulmonary dysplasia (23 to 5%). Among VLGAI, all of these results were also significant. Neonatal mortality and morbidity were not different. Conclusions:In our setting, combining two individualized lung recruitment maneuvers at birth was feasible and may be beneficial on short-term and before discharge pulmonary outcomes. A randomized controlled trial is needed to confirm these results.

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Section: Discussionsupporting

confidence: 67%

Feasibility of combining two individualized lung recruitment maneuvers at birth for very low gestational age infants: a retrospective cohort study

Kanaan

Bloch-Queyrat²,

Boubaya³

et al. 2020

BMC Pediatr

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“…We studied surfactant-deficient 124–127 days’ preterm lambs (term ~145 days) born via caesarean section under general anaesthesia to ewes that received 11.7 mg of betamethasone 24 and 48 hours prior to delivery 10. Lambs were instrumented before delivery, including applying a custom-built electrical impedance tomography (EIT) belt around the chest as described in detail previously 21 26. At delivery, the lambs were weighed, placed supine and anaesthesia and analgesia maintained with ketamine and midazolam infusions at doses that suppressed spontaneous breathing.…”

Section: Methodsmentioning

confidence: 99%

“…Peripheral oxygen saturation (SpO 2 ), heart rate, arterial blood pressure (HP48S monitor, Hewlett Packard, Andover, MA, USA), airway pressure, gas flow and tidal volume (Vt) at the airway opening (Florian, Acutronic Medical Systems, Hirzel, Switzerland) were measured continuously from birth. Global and regional lung volume changes were acquired by EIT (Pioneer System, Swisstom, Landquart, Switzerland) at 48 scans/s 21 26 27. Arterial blood analysis was performed at 5 min and every 15 min from birth.…”

Section: Methodsmentioning

confidence: 99%

“…In our previous work, we also observed that the response to exogenous surfactant therapy was blunted in preterm lambs that had first received an SI compared with a dynamic PEEP (DynPEEP) escalation/de-escalation recruitment manoeuvre 15 20. However, this study had the limitations of small group size (n=9–10/group), no antenatal corticosteroids, the lack of a no-recruitment control group and the use of an SI that, although clinically relevant, did not fully aerate the lung 21 22…”

Section: Introductionmentioning

confidence: 90%

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Aeration strategy at birth influences the physiological response to surfactant in preterm lambs

Tingay

Togo

Pereira‐Fantini

et al. 2019

Arch Dis Child Fetal Neonatal Ed

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BackgroundThe influence of pressure strategies to promote lung aeration at birth on the subsequent physiological response to exogenous surfactant therapy has not been investigated.ObjectivesTo compare the effect of sustained inflation (SI) and a dynamic positive end-expiratory pressure (PEEP) manoeuvre at birth on the subsequent physiological response to exogenous surfactant therapy in preterm lambs.MethodsSteroid-exposed preterm lambs (124–127 days’ gestation; n=71) were randomly assigned from birth to either (1) positive-pressure ventilation (PPV) with no recruitment manoeuvre; (2) SI until stable aeration; or (3) 3 min dynamic stepwise PEEP strategy (maximum 14–20 cmH2O; dynamic PEEP (DynPEEP)), followed by PPV for 60 min using a standardised protocol. Surfactant (200 mg/kg poractant alfa) was administered at 10 min. Dynamic compliance, gas exchange and regional ventilation and aeration characteristics (electrical impedance tomography) were measured throughout and compared between groups, and with a historical group (n=38) managed using the same strategies without surfactant.ResultsCompliance increased after surfactant only in the DynPEEP group (p<0.0001, repeated measures analysis of variance), being 0.17 (0.10, 0.23) mL/kg/cmH2O higher at 60 min than the SI group. An SI resulted in the least uniform aeration, and unlike the no-recruitment and DynPEEP groups, the distribution of aeration and tidal ventilation did not improve with surfactant. All groups had similar improvements in oxygenation post-surfactant compared with the corresponding groups not treated with surfactant.ConclusionsA DynPEEP strategy at birth may improve the response to early surfactant therapy, whereas rapid lung inflation with SI creates non-uniform aeration that appears to inhibit surfactant efficacy.

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“…Previous trials to evaluate the efficacy and effectiveness of sustained lung inflation on preterm infants that enrolled preterm infants of different gestational age and birth weight have shown the inconsistent result in short‐term outcomes . Animal studies have shown an inverse relationship between gestational age and lung aeration from sustained lung inflation, so the response to sustained inflation may vary with the size and gestational age of an infant. The SAIL trial performed well under CONSORT assessment and concluded that sustained lung inflation should not be used in this patient population.…”

mentioning

confidence: 99%

Sustained lung inflation does not decrease bronchopulmonary dysplasia or death among extremely preterm infants: A Commentary on The SAIL randomised clinical trial

Pandey

Sapkota

2019

Acta Paediatrica

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The CONSORT guidelines allow for meaningful assessment of how randomised controlled trials have been designed, analysed and reported, and a thorough evaluation of a RCT within the context of these guidelines allows for fair interpretation of the data presented. 1 Title and abstract sections of the article identifies the trial as a randomised trial and includes a structured summary of trial design, method, result and conclusion. 2 The introduction section includes the scientific background, rationale as well as specific objectives of whether sustained lung inflation at birth reduces bronchopulmonary dysplasia (BPD) or death which is a relevant topic as the rates of BPD remain high. 3Method section describes the trial design (parallel-group trial with permuted block randomisation), eligibility criteria, settings and locations of participants. There were no critical changes in the method after starting the trial. Interventions to each group and outcomes, both primary and secondary, were defined in sufficient detail. The sample size was calculated to detect absolute risk reduction of death or BPD by 12.5% with 80% power and 2-sided α = 0.038 (adjusted P-value for two planned interim analyses). The authors had pre-specified planned interim analysis and stopping rules. Computer-generated parallel-group randomisation was done, and the trial was not blinded. Statistical analysis, for primary and secondary analyses, as well as subgroup analyses and sensitivity analyses were robust. Flow diagram accounting for all enrolled infants was presented.The investigators planned to recruit 600 infants but trial was stopped early after recruiting 426 infants as predefined secondary safety endpoint was met when the data and safety monitoring committee reported suggestion of higher death in the sustained inflation group within the first 48 hours of life compared to control group (7.4% vs 1.4% aRD, 5.6% [95% CI, 2.1% to 9.1%]; P = .002). Baseline characteristics of the two groups were comparable. Primary outcomes death or BPD at 36 weeks, as well as death and BPD at 36 weeks, were not different between the groups. There were no significant differences in secondary outcomes.The discussion section mentions the limitations of the article.The article does not report the comparative outcomes between the centres where sustained lung inflation was routine versus the centres where the procedure was investigational. These findings would be meaningful because the familiarity of the procedure may change the outcomes. The trial is registered in clinicaltrials.gov, the full protocol is available, and funding information is provided.Previous trials to evaluate the efficacy and effectiveness of sustained lung inflation on preterm infants that enrolled preterm infants of different gestational age and birth weight have shown the inconsistent result in short-term outcomes. 4-6 Animal studies have shown an inverse relationship between gestational age and lung aeration from sustained lung inflation, 7 so the response to sustained inflation may vary with t...

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Time to lung aeration during a sustained inflation at birth is influenced by gestation in lambs

Cited by 25 publications

References 41 publications

Feasibility of combining two individualized lung recruitment maneuvers at birth for very low gestational age infants: a retrospective cohort study

Feasibility of combining two individualized lung recruitment maneuvers at birth for very low gestational age infants: a retrospective cohort study

Aeration strategy at birth influences the physiological response to surfactant in preterm lambs

Sustained lung inflation does not decrease bronchopulmonary dysplasia or death among extremely preterm infants: A Commentary on The SAIL randomised clinical trial

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