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Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, MD,A Myra H

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Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, MD,A Myra H Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, MD,a Myra H. Wyckoff, MD,a Vishal Kapadia, MD,a Mambarambath Jaleel, MD,a Venkatakrishna Kakkilaya, MD,a L. Steven Brown, MS,b David B. Nelson, MD,c Luc P. Brion, MDa BACKGROUND: In 2011, the Neonatal Resuscitation Program (NRP) added consideration of abstract continuous positive airway pressure (CPAP) for spontaneously breathing infants with labored breathing or hypoxia in the delivery room (DR). The objective of this study was to determine if DR-CPAP is associated with symptomatic pneumothorax in infants 35 to 42 weeks’ gestational age. METHODS: We included (1) a retrospective birth cohort study of neonates born between 2001 and 2015 and (2) a nested cohort of those born between 2005 and 2015 who had a resuscitation call leading to admission to the NICU and did not receive positive-pressure ventilation. RESULTS: In the birth cohort (n = 200 381), pneumothorax increased after implementation of the 2011 NRP from 0.4% to 0.6% (P , .05). In the nested cohort (n = 6913), DR-CPAP increased linearly over time (r = 0.71; P = .01). Administration of DR-CPAP was associated with pneumothorax (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 4.4–6.8); the OR was higher (P , .001) in infants receiving 21% oxygen (OR: 8.5; 95% CI: 5.9–12.3; P , .001) than in those receiving oxygen supplementation (OR: 3.5; 95% CI: 2.5–5.0; P , .001). Among those with DR-CPAP, pneumothorax increased with gestational age and decreased with oxygen administration. CONCLUSIONS: The use of DR-CPAP is associated with increased odds of pneumothorax in late- preterm and term infants, especially in those who do not receive oxygen in the DR. These findings could be used to clarify NRP guidelines regarding DR-CPAP in late-preterm and term infants. aDivision of Neonatal-Perinatal Medicine, Department of Pediatrics and cDivision of Maternal-Fetal Medicine, WHAT’S KNOWN ON THIS SUBJECT: Continuous Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, Texas; and bParkland Health positive airway pressure (CPAP) is a risk factor for and Hospital System, Dallas, Texas pneumothorax. New Neonatal Resuscitation Program Dr Smithhart conceptualized and designed the study, merged the spreadsheets of the 2 databases, guidelines included CPAP as a possible corrective and wrote the first draft of the manuscript; Drs Wyckoff, Jaleel, Kapadia, Nelson, and Kakkilaya measure for spontaneously breathing infants who conceptualized and designed the study; Mr Brown conducted statistical analyses; Dr Brion have labored breathing or persistent cyanosis. conceptualized and designed the study and conducted statistical analyses; and all authors WHAT THIS STUDY ADDS: Among late-preterm and participated in the interpretation of the data, critically reviewed the revisions, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. term infants, pneumothorax increased after implementation of the new Neonatal Resuscitation DOI: https://doi.org/10.1542/peds.2019-0756 Program guidelines. Delivery room CPAP was Accepted for publication May 28, 2019 associated with pneumothorax. The odds ratio was Address correspondence to Luc P. Brion, MD, Division of Neonatal-Perinatal Medicine, Department of higher in infants receiving 21% oxygen than in those Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, STOP 9063, receiving oxygen supplementation. Dallas, TX 75390-9063. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Smithhart W, Wyckoff MH, Kapadia V, et al. Delivery Room Continuous Positive Airway Pressure and Copyright © 2019 by the American Academy of Pediatrics Pneumothorax. Pediatrics. 2019;144(3):e20190756 Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 3, September 2019:e20190756 ARTICLE The use of delivery room (DR) preterm infants that is caused by RDS with short-term PPV with a self- continuous positive airway pressure or retained lung fluid (both inflating bag. Only the NICU (CPAP) has increased in preterm associated with decreased lung resuscitation team can provide CPAP infants in recent years,1 likely compliance). However, in term or positive end-expiratory pressure to because of lower risk of the combined infants, RDS prevalence is low. newborns in the DR. Facemask CPAP outcome of death or Grunting, nasal flaring, or retractions is provided via NeoPuff T-piece bronchopulmonary dysplasia, as may result from diagnoses for which resuscitator. CPAP is typically started compared with DR endotracheal DR-CPAP administration is not at 5 cm H2O and further escalated to intubation.2,3 DR intubation a proven therapy, such as fetal a maximum of 8, if needed, in the DR decreased in preterm infants at acidemia, perinatal asphyxia, or later in the NICU, on the basis of Parkland Health and Hospital System pulmonary hypertension, chest radiograph findings and oxygen (PHHS) as well,4 coinciding with pneumothorax, congenital requirement. PHHS adopted the NRP participation (2005–2009) in the diaphragmatic hernia, polycythemia, guidelines including DR-CPAP in Surfactant, Positive Pressure, and fever, sepsis, or hypoglycemia.14,15 spontaneously breathing infants with Oxygenation Randomized Trial Therefore, we hypothesized that in respiratory distress or hypoxia in July (SUPPORT), in which researchers late-preterm and term infants, the use 2011. Criteria for NICU admission are compared DR intubation to DR- of DR-CPAP would be associated with listed online (Supplemental CPAP.5 New guidelines were increased frequency of symptomatic Information). published in 2010 and implemented pneumothorax. by the Neonatal Resuscitation Data Sources Program (NRP) in 2011, which METHODS Data were obtained from the included CPAP as a possible Parkland neonatal resuscitation and corrective measure for spontaneously Design NICU databases. The neonatal breathing infants without apnea, This was a retrospective birth cohort resuscitation database is gasping, or heart rate ,100 beats per study with a nested cohort. a compilation of data since 2005 minute who have labored breathing pertaining to DR resuscitation of or persistent cyanosis, regardless of Patients newborns who are admitted to the gestational age (GA).6,7 Entry criteria for the birth cohort NICU as well as data at the time of admission to the NICU. The Parkland CPAP improves oxygenation in included infants 35 to 42 weeks’ GA NICU database provides data during preterm infants with respiratory born at PHHS between 2001 and their NICU stay. distress syndrome (RDS).8 CPAP may 2015. To further assess the effects of also improve functional residual DR-CPAP, we selected a nested cohort capacity, respiratory work, and gas of at-risk infants (1) treated by Outcome Variables exchange.9 The effect of positive a resuscitation team (which could The primary outcome of the birth pressure on lung volume increases provide DR-CPAP), (2) with extensive cohort was the change in percentage with lung elasticity, which is directly available information (available in of pneumothorax after related to GA, and decreases with those born between 2005 and 2015 implementation of the new NRP chest wall elasticity, which is who were admitted to the NICU), and guidelines. inversely related to GA.7,10 The (3) excluding those who received DR The primary outcome of the nested amount of pressure required to cause positive-pressure ventilation (PPV). cohort was the odds ratio (OR) of lung rupture decreases with pneumothorax of infants who increasing GA because of increased Setting received DR-CPAP versus those who distensibility and decreased surface At PHHS, deliveries for infants 35 to did not receive DR-CPAP. Secondary tension.11 The association between 42 weeks’ GA are typically attended outcomes included the use of DR- CPAP and air leak syndrome has been by a provider from the newborn CPAP and the comparison of OR of a concern in neonatal literature.12 In nursery who may use PPV without pneumothorax with CPAP in infants the Continuous Positive Airway positive end-expiratory pressure, receiving 21% oxygen in the DR Pressure or Intubation at Birth using a self-inflating bag. The PHHS versus OR in those receiving oxygen (COIN) trial, increased air leak in DR- NICU resuscitation team is called for supplementation. CPAP versus DR intubation may have infants 35 to 42 weeks’ GA at high resulted from a higher level of CPAP risk for needing resuscitation (eg, than in similar studies.4,13 CPAP is an malformations), fetal compromise (ie, Approval appropriate DR therapy for most nonreassuring fetal heart tones), or This study was approved by the hypoxia or labored breathing in poor respiratory effort not resolving University of Texas Southwestern Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 SMITHHART et al Medical Center Institutional Review Board and by PHHS. Statistical Analysis Continuous variables are presented as mean (SD) or median (interquartile range). Changes over time (with participation in SUPPORT and after implementation of the new NRP guidelines) were analyzed either by statistical process control (P control chart) by using QI Macros for Excel (KnoWare International, Denver, CO) if values were stable or by time series analysis to analyze significance of trends. Other statistical analyses were conducted by using SPSS version 23 (IBM, Inc, FIGURE 1 Armonk, NY) or SAS version 14.2 Study participant flow diagram showing the birth cohort (infants 35–42 weeks’ GA born in – – ’ – (SAS Institute, Inc, Cary, NC) for 2- 2001 2015) and the nested cohort (infants 35 42 weeks GA born in 2005 2015 who had a DR resuscitation team call, did not receive PPV in the DR, and were admitted to the NICU). O , oxygen. tailed tests, with P , .05 considered 2 significant. Continuous variables were included all variables available in the To detect a 25% increase in analyzed by using Student t test, DR (excluding CPAP) and soon after frequency of pneumothorax in the Mann-Whitney test, or time series NICU admission that reached birth cohort from a baseline of 0.4% analysis.
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