Respiratory monitoring to improve neonatal support at birth

The assessment of an infant’s condition at birth or during resuscitation remains mostly clinical and can be a challenge for practitioners [1-3]. In 2005, the addition of the transcutaneous oxygen saturation monitoring was suggested in the European guidelines [4] only to become part of AAP and ERC recommendations in 2010 [5, 6] By contrast, in the NICU, data from multimodal monitoring systems are generally integrated to the clinical evaluation to optimize newborn infants’ intensive care. Thus, respiratory mechanic information’s given by the ventilator provides useful informations on pressure, volume, leaks and respiratory function of the intubated infant [7]. While ventilation is the main intervention to support difficult transition to extra-uterine life, monitoring infants and medical procedures is only slowly integrating clinical practice in the delivery room [8]. Use of an experimental respiratory function monitor (RFM) at birth was suggested initially in 1984 in a study evaluating mask and bag ventilation in 9 term infants [9]. It reappeared 30 years later in a manikin study that discussed future use for research and as a training tool [10]. The RFM is connected to a computer for recording. A hot wire anemometer interposed between the mask and the pressure providing device (self-inflating bag SIB or T-piece) supply flow data, and therefore informations on tidal volume (VT), inspiratory and expiratory times, and leaks. The pressure line can be fitted at the T-piece gas inlet, the T-piece itself, or at a port on the SIB. Oxygen concentration can be quantified at the gas inlet, and integrated to the recording. Additionally, the software can accommodate heart rate and oxygen saturation data from a pulse oxymeter. A small webcam can also document both the infant’s visual aspect and actions undertaken. Clinical and simulation studies did highlight some technical difficulties of birth resuscitation and suggested ways to overcome them. Holding the face mask appropriately is surprisingly a difficult task. Large leaks are common, and are associated with lower VT’s [11]. Use of RFM in simulation studies allowed to investigate placement and hold of face masks [12]. Trainees also improved their technique when provided with RFM feedback [13]. RFM has been used to evaluate different pressure providing devices [14, 15]. The negative influence of chest compressions on the efficacy of manikin ventilation was documented with RFM [16]. In clinical practice, RFM was shown to decrease mask leak and helped to avoid excessive VT [17]. Currently, a randomized controlled trial evaluates if guiding neonatal resuscitation with RFM will improve infants’ outcomes. Studies with RFM in the delivery room did improve our understanding of respiratory adaptation at birth. Patterns of initial respirations have been further characterized, with long or delayed expirations observed mostly in preterm infants [18]. Very preterm infants’ respiration starts with increasing VT’s followed by smaller breaths and increased CO2 exhalation[19]. With face mask ventilation, VT’s have a large variability, with lower volumes occurring when active inspiration is absent [11]. Additionally, obstructive phenomena (when positive pressure is not associated with insufflatory flow) seem common in the first minutes of life [20]. Our neonatal stabilization room now benefits from a RFM. This tool already has multiple applications. For new residents and for outreach training, the RFM helps to improve mask ventilation teaching on a leak-free manikin. Combined video and RFM recordings can be reviewed for educational and auditing purposes. We used it in a manikin study, to assess if different types of small manometers could improve bag and mask ventilation. Finally, RFM helps to evaluate the outcome of a resuscitation intervention in a randomized controlled trial. We are investigating the effect of either prophylactic suction before ventilation (as recommended by the AAP [6]) or no systematic suction (as in the ERC guidelines [5]) on the incidence of airway obstructions and neonatal adaptation

Automated respiratory cycles selection improves the variability of respiratory mechanics monitoring.

peer reviewe

The Good, the Bad, the Marginal: respiratory management of <29 weeks infants according to subjective assessment of perinatal adaptation.

Background Even if a primary CPAP strategy gives benefits in extremely preterm infants, many still require intubation at birth. Half of those initially managed with primary CPAP will require further support: surfactant administration or mechanical ventilation. Those infants have increased risks of death and neonatal morbidities, and will require longer duration of respiratory support. Identifying them early, during the birth stabilization process, might lead to improvements in respiratory care. A subjective classification of perinatal adaptation as Good, Bad or Marginal has been suggested but requires further evaluation. We aimed to evaluate respiratory management according to perinatal adaptation. Methods Premature infants of less than 29 weeks and admitted between 01/2013 and 07/2014 were retrospectively studied. Neonatal database and discharge summaries provided neonatal care and outcome data. Good perinatal adaptation (GPA) was considered for infants with good respiratory drive, tone and low oxygen requirement in the delivery room. Infants with marginal (M) PA had intermittent respiratory drive, normocardia with ventilation, and decreasing FiO2. Bad (B) PA is considered with hypotonia, bradycardia, apnea and high FiO2. Data are presented as mean +/- SD, median (interquartile range) or incidence and analyzed with ANOVA, Kuskal-Wallis test or Chi2. Results Sixteen infants had GPA, 19 MPA and 23 BPA. GA was 26 4/7 wk (24-28) and BW was 885 187g. Risk factors for bad adaptation are (NS) male gender, lower GA, and no complete antenatal steroid exposure. Apgar at 1 min. increases with better PA [B3 (2-5); M6 (3-7) and G8 (7-8)*] (*p<.05 vs B & M), and improves at 5 min.: [B7 (6-7); M7 (6-8); G 9 (8-9)*]. Risk of intubation at birth is associated with poorer adaptation (B 87%; M 47%; G 12%, p<.01) Primary CPAP success was not different according to group (B 3/3; M66%; G56%). Surfactant while on CPAP (LISA method) was given to 11/16 patients, including 7 delivery room administrations. If intubated by day 3, duration of first invasive ventilation was shorter (NS) for GPA (9h) [MPA (15h), BPA (29h)]. Early neonatal death tended to decrease with better PA: 26%, 16% and 0% (p=.08). There is no difference in BPD -36 wk (B 19%, M13%, G 12%). Conclusions Infants with better perinatal adaptation have increased chances of being initially managed with CPAP. Primary CPAP success may be improved with less invasive surfactant therapy. Outside of the delivery room, perinatal adaptation assessment tends to identify risk of early neonatal death, but is not predictive of respiratory outcomes

Ajustement des marqueurs d’insertion des tubes endotrachéaux selon l’âge gestationnel.

peer reviewedIntroduction et objectifs: le positionnement adéquat d’un tube endotrachéal (TET) peut être difficile en raison de la marge de manœuvre limitée associée aux faibles distances laryngo-trachéales du prématuré. Les marqueurs distaux censés faciliter l’évaluation de ce positionnement ne sont pas standardisés entre les fabriquants, et le marquage généralement unique par taille de tube ne tient pas compte de la croissance associée à l’âge gestationnel. L’objectif de l’étude est de décrire les distances entre les cordes vocales (CV) et la moitié de la trachée en fonction de l’âge gestationnel et proposer des nouveaux marquages adaptés. Méthodes : la moitié de la longueur de la trachée ajoutée à la hauteur de la lame postérieure du cricoïde permet d’estimer la distance entre les CV et la moitié de la trachée (CV-MiTr). Ces longueurs sont issues à postériori d’une base de données prospective reprenant les distances détaillées du larynx et de la trachée mesurées lors d’autopsies de fœtus et nouveau-nés exempts de malformation des voies respiratoires (Fayoux et coll., Journal of anatomy 2008). Une corrélation est établie avec l’âge gestationnel. Résultats : les données proviennent de 121 patients. Il existe une corrélation linéaire entre la distance CV-MiTr et l’AG (r=0,91; y=2,6043+0,6275x; p<.0001). Des marqueurs d’insertion positionnés à 17,7; 18,9; 20,8; 22,7; 24,6 et 26,4 mm correspondraient à des AG de 24, 26, 29, 32, 35 et 38 semaines respectivement. Ils pourraient être indiqués par des lignes de couleurs contrastées. Conclusion : la relation linéaire entre la distance CV-mi-trachée et l’AG donne l’opportunité de revoir les marqueurs d’insertion des tubes endotrachéaux pour les patients les plus petits. Ces nouveaux marqueurs devraient être comparés cliniquement à ceux actuellement en usage avant d’être généralisés

Instillation de surfactant chez le prématuré en respiration spontanée : méta-analyse

peer reviewedJustification: Lors du traitement par surfactant dit moins invasif (Less invasive surfactant therapy- LIST), le produit est instillé dans la trachée par un cathéter fin alors que l’enfant respire spontanément sous CPAP. Différentes études ont donné des résultats variables mais encourageants. L’objectif de cette méta-analyse est de comparer le devenir respiratoire des prématurés traités par LIST avec celui de ceux traités par administration de surfactant par un tube endotrachéal. Méthodes : les études randomisées contrôlées (ERC) sont recherchées dans les bases de données et dans les références d’articles pertinents. Les devenirs respiratoires (dysplasie broncho-pulmonaire (DBP), décès ou DBP, échec précoce de CPAP, nécessité de ventilation invasive) et les morbidités classiques sont reprises de ces études. Pour chaque morbidité, le risque relatif (RR) des données mutualisées est calculé avec une analyse de Mantel-Haenszel à modèle d’effet aléatoire. Le RR est également calculé pour des sous-groupes établis selon l’intervention contrôle. Résultats : six ERC évaluent le LIST : 4 le comparent à l’INSURE (Intubation-Surfactant-Extubation), et les 2 autres à l’intubation (immédiate ou après maintient en CPAP) avec surfactant. Les méthodes LIST diminuent les risques de DBP (RR= 0,71 (0,52-0,99) ; nombre nécessaire à traiter NNT= 21), et de décès ou DBP (RR= 0,7 (0,58- 0,94) ; NNT= 15). L’échec précoce de CPAP et le recours à la ventilation invasive sont également réduits (RR= 0,67 (0,53-0,84) ; NNT= 8 et RR= 0,69 (0,53- 0,88) ; NNT= 6). Comparé à l’INSURE, le LIST diminue le risque combiné de décès ou DBP (RR= 0,63 (0,44-0,92) ; NNT= 11), et d’échec précoce de CPAP (RR=0,71 (0,53-0,96) ; NNT= 11). Les autres morbidités néonatales classiques sont similaires pour les différents groupes. Conclusions : une stratégie d’administration dite moins invasive de surfactant diminue les risques de morbidité respiratoire à moyen terme (DBP, décès ou DBP) et le recours à la ventilation invasive. Cette approche semble sure mais les données de suivi à long terme sont insuffisantes

Lock Gates - Innovative concepts

This paper introduces some new innovative concepts identifies by the INCOM WG29 and reported in the PIANC report 106 “Innovations in Navigation Lock Design”, 2009.The paper focusses on innovation in LOCK GATESPeer reviewe

The Effect on Systemic and Pulmonary Circulations in the Resuscitation of Asphyxiated Newborn Piglets with 21%, 50% or 100% Oxygen

peer reviewe

Early enterovirus neonatal infection: when should we think about it?

peer reviewedEnterovirus (EV) may cause a broad spectrum of clinical syndromes and even cause a sepsis-like picture. Although they are responsible for high morbidity and mortality rates, viral testing does not appear in the algorithms for the evaluation of neonatal infections. During the month of June 2013, we identified 3 cases of EV meningitis in our unit of neonatology. All three infants had fever during the first week of life and their clinical examination revealed an irritability. The EV infection was detected by Real-Time Polymerase Chain Reaction (RT-PCR) EV on the cerebrospinal fluid (CSF). Two of the patients also had a positive RT-PCR EV in the blood. The 3 newborns were discharged from the hospital after a few days with no adverse outcome. Our clinical observations and the literature review suggest that EV infections in neonates ought to be identified as soon as possible by an early RT-PCR EV on the blood, and on the CSF if a lumbar puncture is indicated. This could help reduce the administration of antibiotics and the length of hospital stay.Les entérovirus (EV), peuvent causer des infections néonatales dont les manifestations sont extrêmement variables, mimant parfois celles d’un sepsis bactérien. Bien qu’elles soient responsables d’un taux élevé de morbidité et de mortalité, leur recherche ne fait pas partie du bilan classique devant une suspicion d’infection néonatale. Au cours du mois de juin 2013, nous avons identifié 3 cas de méningite à EV dans le service de néonatologie. La symptomatologie était dominée par une irritabilité, dans un contexte de fièvre, au cours de la première semaine de vie. Le diagnostic a été posé par Real-Time Polymerase Chain Reaction (RT-PCR) EV sur le liquide céphalo-rachidien (LCR). La RT-PCR était également positive sur le sang chez les 2 patients testés. Dans les 3 cas, l’évolution a été rapidement favorable

Small manometers improve bag and mask ventilation: a manikin study

INTRODUCTION: Self-inflating bags (SIB) remain widely used for neonatal resuscitation. Insufflation pressures from SIB are difficult to assess and can be inadequate. Ventilation monitoring improves pressure control, but is not accessible to most resuscitators. Small spring manometer or a pressure line to a needle and dial manometer can be connected through a side port on the SIB. Those devices are cheap and easily available, but their efficacy needs to be assessed. Observation of the manometer could also be considered as a distraction, with increased risk of leak or inadequate insufflation rate. We therefore aimed to evaluate the effect of mechanical manometers on the quality of insufflations with a SIB. MATERIALS AND METHODS: Participants to the Belgian Pediatric Society meeting were invited to ventilate a manikin with a 300 ml SIB. The leak-free manikin was modified with a flow-meter at tracheal level connected to a neonatal test lung. Participants had to aim for a 25 mbar pressure and a rate of 40-60 during 3 sequences of 45 seconds. A spring (S), a dial (D) manometer or nothing (N) was added to the SIB in random sequence. Pressure data from the SIB and flow data from the manikin were obtained through a ventilation monitor. Peak pressure (PIP), tidal volume (VTi), and insufflations rate (RR) were calculated for each breath. Theoretical leak was evaluated by subtracting real from theoretical volumes derived from a leak free calibration (taped facemask). Data were analyzed with ANOVA and posthoc Bonferroni. RESULTS Five neonatologists (Neo), 15 pediatricians (Ped) and 11 residents ventilated the manikin for a total of 5279 insufflations. Manometer use was associated with an increase in PIP (N: 17+-6 mbar; S: 18+-4 mbar*; D: 19+-4 mbar*#) [*p<.05 vs N; #:p<.05 vs S]. Changes in VTi (N: 3+-1 ml; S: 3.1+-1 ml*; D: 3.2+-1 ml*) and RR (77-82 bpm) were small. Leak did not increase. The effect of manometer use on PIP, VTi and leak was more important with Neo (PIP-N: 16+-7 mbar; S and D: 20+-4 mbar*) and Ped. With residents, no change occurred in PIP (~17 mbar), Vti (2.9 ml) or leak (31-35%). However, for first sequences of ventilation, manometer use was associated with higher PIP (N: 12+-4 mbar; S: 16+-3 mbar*; D: 20+-4 mbar*#), VTi (N:2+-1 ml; S:3+-0.8 ml*; D:3.3+-1 ml*#) and lower leaks (N: 38+-16%; S: 27+-12%*; D: 34+-13%*#). This observation for first sequences was found in all 3 categories of providers. CONCLUSIONS Bag and mask ventilation remains difficult. In this model, the addition of a manometer is associated with improved pressures and VTi, and with decreased theoretical leak. This effect is predominant for initial (“naïve”) ventilation with a dial manometer, and is also related to operator experience. Small, inexpensive manometers have the potential to improve SIB ventilation of newborn infants