Respiratory Support During Neonatal Resuscitation

Respiratory support during neonatal resuscitation

Georg M Schmölzer Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Dept. of Pediatrics, University of Alberta, Edmonton, Canada Disclosure

GM Schmölzer is supported by: • Heart and Stroke Foundation Alberta Professorship of Neonatal Resuscitation • Heart and Stroke Foundation Canada - New Investigator Award Funding • Canadian Institute of Health Research • Heart and Stroke Foundation Canada • Neonatal Resuscitation Program, AAP & CP

• Member of ILCOR since 2015 Objectives

• Fetal to neonatal Transition • How much oxygen should we use? • Respiratory support - What to do? • What ventilation device and interface? • What about PEEP? • SI or just PPV at birth? Objectives

• Majority of infants do not need help • With lower gestational age an increasing number of infants do need help • ~80% of infants breathe and cry at birth1 • Different expiratory breathing patterns2 • Lungs after birth partially liquid-filled

• Clear lung liquid • Establish functional residual capacity • Initiate spontaneous breathing • Facilitate gas exchange

1O’Donnell CPF et al JPeds 2011 2te Pas AB et al Ped Res 2008 Lung liquid clearance Lung liquid clearance

CO2 CO2

CO2 CO 2 CO2 CO2 Fetal to Neonatal Transition

• When infants fail to breathe after birth - Need to support breathing (CPAP/PEEP and/or PPV and/or SI) • The goals of PPV are: • Clear lung liquid • Establish functional residual capacity

• Deliver adequate VT • Facilitate gas exchange • Stimulate breathing

• While minimizing lung injury Objectives

• Newborns >35 weeks’ begins with 21% O2

• Newborns <35 weeks’ begins with 21% to 30% O2 • Use a Blender to adjust oxygen concentration as needed to achieve SpO2 target

Perlman et al. Circulation 2015 Reference ranges of SpO2

Dawson JA et al, Pediatrics 2010 How much oxygen should we use?

Oei JL et al, Acta Pædiatrica 2016 How much oxygen should we use?

• Using <1.0 FiO2 to initiate DR resuscitation is a relatively new practice

• Lack of evidence for preterm-specific SpO2 targets • During the first 10 min after birth of life • Neurodevelopmental outcomes How much oxygen should we use?

• The TO2RPIDO compared babies <32 weeks resuscitated with either FiO2 0.21 or 1.0 • Study was closed early after recruiting only 292 patients • Post hoc analysis • Significantly increased hospital mortality in infants <29 (28+6) resuscitated with FiO2 0.21 (10/46 (22%) vs. 1.0 (3/54 (6%), OR, 95% CIs 0.2 (0.05 to 0.8, p=0.03)

Oei JL et al, ADC FN 2016 How much oxygen should we use?

• Data from 17 NICUs included 2326 infants • 1244 in the OXtitrate group and 1082 in the OX100 group. • The AOR for the primary outcome of severe neurologic injury or death was higher in the OXtitrate group compared with the OX100 group (AOR 1.36; 95% CI 1.11, 1.66) • A similar increase was also noted when comparing infants initially resuscitated with room air to the OX100 group (AOR 1.33; 95% CI 1.04, 1.69) • In Canadian NICUs, we observed a higher risk of severe neurologic injury or death among preterm infants of ≤27 weeks

Rabi Y et al, Resuscitation 2015 Implications for practice

• Use current recommendations until new evidence is available

• Well-designed and adequately powered RCTs are needed • PRESOX closed 2017 - lack of recruitment • PROMOTION-Collaboration • HILO-trial • Torpido 2 Objectives

• Positive Pressure Ventilation (PPV) in preterm infants: • Adjust the flowmeter to 10 L/min

• Initial peak inflating pressure (PIP) 20 to 25 cm H2O

• Use an initial PEEP of 5 cm H2O • If PPV is required for resuscitation of a preterm newborn, it is preferable to use a device that can provide PEEP. • Using PEEP helps the baby’s lungs remain inflated between positive pressure inflations

Perlman J et al. Circulation 2015 Ventilation devices

• Self-inflating bags, flow-inflating bags or T-piece devices may all be used for mask ventilation1 T-Piece preferred ventilation device2: • 31% in Ireland • 45% in Spain • 80% in Austrian • 41% in German • 20% in Swiss

1Perlman J et al. Circulation 2015 2Hawkes CP et al. Resuscitation 2012 The effect of a PEEP valve on a Laerdal neonatal self-inflating resuscitation bag

Morley C et al. Journal of Paediatrics and Child Health 2010 Implications for practice

• Self-inflating • Does not provide PEEP or CPAP • An attached PEEP-valve provides inconsistent PEEP and cannot deliver CPAP • Flow-inflating bag • Variable and operator dependent PEEP • T-piece device • Consistent, predetermined level of PEEP and PIP • Most accurate device for delivering SI O’Shea J et al, ADC FN 2016 Interface

• Face Masks • Round silicone mask most common

• Nasal Prongs • Shortened endotracheal tube • Large leaks from mouth or contralateral nostril Enemy of Mask Ventilation

• Reduces delivered VT • Varies between resuscitators1 • Mask leak >75% in 50% of analyzed resuscitations2

1Schmölzer GM et al ACD FN 2010 2Schmölzer GM et al ADC FN 2010 Schmölzer GM et al ACD F&N 2009 Airway Obstruction

Airway obstruction during PPV is common1 • 75% of infants had obstructed inflations • Pedi-Cap during PPV to identify airway obstruction • 25% of infants had severe airway obstruction2

1Finer NN et al Pediatrics 2009 2Schmölzer GM et al ADC FN 2010 Mask ventilation with two different face masks in the delivery room for preterm infants: a randomized controlled trial

Cheung D et al. Journal of Perinatology 2015 Mask ventilation with two different face masks in the delivery room for preterm infants: a randomized controlled trial

Cheung D et al. Journal of Perinatology 2015 Nasal Prong or Face Mask for Respiratory Support for Preterm Newborns

Intubation

Chronic lung disease

Schmölzer, unpublished data Implications for practice

• Different face mask have similar leaks • Both interfaces can be used during respiratory support at birth • Staff needs to be trained with the device used in their hospital Objectives

• Fetal to neonatal Transition • How much oxygen should we use? • Respiratory support - What to do? • What ventilation device and interface? • What about PEEP? • SI or just PPV at birth?

CPAP or PEEP during resuscitation

• Helps establish and maintain the FRC • Decreases airway resistance • Improves lung compliance • Regularizes & slows respiratory rate • Reduces apnoea • Improves oxygenation • Conserves surfactant • Reduces lung injury and inflammation • Reduces the need for ventilation Optimal PEEP at birth

• PPV without PEEP • repeated collapse and reopening of alveoli • PPV with PEEP

• PEEP of 8 cm H2O increased oxygenation1,2

• compared to PEEP of 0 or 4 cm H2O • Better oxygenation compared to surfactant3

1Probyn ME et al. Acta Paediatr 2005 2Probyn ME et al. Ped Res. 2004 3Crossley KJ et al. Ped Res. 2007 Siew M et al 2009 Courtesy of Stuart Hooper Courtesy of Stuart Hooper T-Piece versus SIB for Ventilation of Extremely Preterm Infants at Birth

Dawson J et al. JPeds 2011 T-Piece versus SIB for Ventilation of Extremely Preterm Infants at Birth

Dawson J et al. JPeds 2011 Comparison of Devices for Newborn Ventilation in the Delivery Room

Szyld et al. JPeds 2014 Comparison of Devices for Newborn Ventilation in the Delivery Room

Szyld et al. JPeds 2014 PEEP vs. NO PEEP during Stabilization in the Delivery Room

Chronic lung disease

Schmölzer, unpublished data Implications for practice

• During stabilization of preterm infants use an interface which can provide PEEP

• Use at least 5cm H2O to support lung aeration Intubate immediately or stabilize on CPAP?

• In observational studies CPAP was associated with lower rate of BPD • Comparison of centres - BPD rates 22% vs. 4%, associated with more use of mechanical ventilation • 261 preterm infants intubation and ventilation with nasal CPAP reported lower mortality and lower rates of administered surfactant, BPD, and IVH • 14 tertiary level neonatal intensive care units in northern Italy - BPD rates Centres with high delivery room intubation rates had higher rates of ventilation and BPD Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

Death

Schmölzer GM et al. BMJ 2013 Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

Death

BPD

Schmölzer GM et al. BMJ 2013 Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

Death / BPD Pooled analysis showed a significant benefit for the combined outcome of death and/or BPD at 36 weeks corrected gestation for babies treated with nCPAP

(RR 0.91 [0.84, 0.99], risk difference -0.04 [-0.07, 0.00], NNT of 25)

Schmölzer GM et al. BMJ 2013 Implications for practice

• Use CPAP before intubation • Try to avoid intubation in the Delivery Room

• One additional infant could survive to 36 weeks without BPD for every 25 babies treated with nasal CPAP in the delivery room rather than being intubated. Open questions PEEP/CPAP

• What is the optimal PEEP/CPAP?

• Difference in outcomes of 21-30% O2 vs. 100% O2? • Does DCC or cord milking compared to earlier cord clamping affects outcomes? • Should we use a PEEP recruitment maneuver to establish FRC? Objectives

T-Piece FIB SIB

Klingenberg et al. Neonatology 2011 SI or just PPV at birth?

• Experimental non-breathing rabbit model: • SI 20” + with PEEP rapid increase in FRC • as did PEEP alone compared to • PPV with or without PEEP

te Pas A et a. Ped Research 2009 Successful vs. unsuccessful SI

Fuchs H et al Ped Res 2011 SI or just PPV at birth?

• Two meta-analyses of SI trials have been published • 2 trials (352 infants) • No significant difference in death during hospitalization or BPD • 4 trials (611 preterm infants) • SI - less mechanical ventilation within 72 hours after birth (RR 0.87, 95% CI 0.77–0.97) • The absolute risk reduction was 0.10 (95% CI 0.17 to 0.03), giving a number needed to treat of 10 • There were no significant differences in the outcomes of BPD, death • Both analyses found an increased rate of medical or surgical treatment for PDA (RR 1.27, 95% CI 1.05– 1.54) • Neither meta-analysis demonstrated a significant difference in air leaks, severe IVH, or other measured neonatal outcomes.

O’Donnell CPF et al Cochrane Rev FN 2015 Schmölzer GM et al, ADC FN 2015 SI or just PPV at birth?

Mechanical Ventilation <72 hours

Death / BPD

Schmölzer GM et al, ADC FN 2015 SI or just PPV at birth?

PDA

Schmölzer GM et al, ADC FN 2015 Using exhaled CO2 to guide initial respiratory support at birth: a randomised controlled trial

Ngan A et al, ADC FN 2017 Ngan A et al, ADC FN 2017 Implications for practice

• The optimal method to safely and effectively aerate the preterm lung is unknown • Sustained inflation is a promising alternative strategy to intermittent PPV with PEEP • There are insufficient data to recommend sustained inflation for routine clinical use at this point Open questions SI

• What is the optimal inflation time? • What inflation pressure(s) are required to establish an effective FRC? • Does DCC or cord milking compared to earlier cord clamping affects outcomes in the presence or absence of SI? • Ongoing randomized trials • Kirpalani et al will include long-term outcomes - SAIL Summary

• Use PEEP/CPAP • Intubate only when needed • People struggle with mask ventilation • Get the lung open • Only then think about oxygen Respiratory support during neonatal resuscitation

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Respiratory support in the DR : What is new?

Georg M Schmölzer Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Dept. of Pediatrics, University of Alberta, Edmonton, Canada