Incomplete Exhalation during Resuscitation-Theoretical Review and Examples from Ventilation of Newborn Term Infants.

BACKGROUND: Newborn resuscitation guidelines recommend positive pressure ventilation (PPV) for newborns who do not establish effective spontaneous breathing after birth. T-piece resuscitator systems are commonly used in high-resource settings and can additionally provide positive end-expiratory pressure (PEEP). Short expiratory time, high resistance, rapid dynamic changes in lung compliance and large tidal volumes increase the possibility of incomplete exhalation. Previous publications indicate that this may occur during newborn resuscitation. Our aim was to study examples of incomplete exhalations in term newborn resuscitation and discuss these against the theoretical background. METHODS: Examples of flow and pressure data from respiratory function monitors (RFM) were selected from 129 term newborns who received PPV using a T-piece resuscitator. RFM data were not presented to the user during resuscitation. RESULTS: Examples of incomplete exhalation with higher-than-set PEEP-levels were present in the recordings with visual correlation to factors affecting time needed to complete exhalation. CONCLUSIONS: Incomplete exhalation and the relationship to expiratory time constants have been well described theoretically. We documented examples of incomplete exhalations with increased PEEP-levels during resuscitation of term newborns. We conclude that RFM data from resuscitations can be reviewed for this purpose and that incomplete exhalations should be further explored, as the clinical benefit or risk of harm are not known.

Associations between unit workloads and outcomes of first extubation attempts in extremely premature infants below a gestational age of 26 weeks.

Objective: The objective was to explore whether high workloads in neonatal intensive care units were associated with short-term respiratory outcomes of extremely premature (EP) infants born <26 weeks of gestational age. Methods: This was a population-based study using data from the Norwegian Neonatal Network supplemented by data extracted from the medical records of EP infants <26 weeks GA born from 2013 to 2018. To describe the unit workloads, measurements of daily patient volume and unit acuity at each NICU were used. The effect of weekend and summer holiday was also explored. Results: We analyzed 316 first planned extubation attempts. There were no associations between unit workloads and the duration of mechanical ventilation until each infant's first extubation or the outcomes of these attempts. Additionally, there were no weekend or summer holiday effects on the outcomes explored. Workloads did not affect the causes of reintubation for infants who failed their first extubation attempt. Conclusion: Our finding that there was no association between the organizational factors explored and short-term respiratory outcomes can be interpreted as indicating resilience in Norwegian neonatal intensive care units.

Tidal volumes and pressures delivered by the NeoPuff T-piece resuscitator during resuscitation of term newborns.

AIM: T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator. METHOD: Observational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1-20) and a late (inflation 21-100) phase. RESULTS: Of the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28-31) and 30 (27-31) mbar, and tidal volume was 4.5 (1.6-7.8) and 5.7 (2.2-9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes. CONCLUSION: There was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30-40 per minute are associated with the highest delivered tidal volumes.

Changes in heart rate from 5 s to 5 min after birth in vaginally delivered term newborns with delayed cord clamping.

OBJECTIVE: To determine heart rate centiles during the first 5 min after birth in healthy term newborns delivered vaginally with delayed cord clamping. DESIGN: Single-centre prospective observational study. SETTING: Stavanger University Hospital, Norway, March-August 2019. PATIENTS: Term newborns delivered vaginally were eligible for inclusion. Newborns delivered by vacuum or forceps or who received any medical intervention were excluded. INTERVENTIONS: A novel dry electrode electrocardiography monitor (NeoBeat) was applied to the newborn's chest immediately after birth. The newborns were placed on their mother's chest or abdomen, dried and stimulated, and cord clamping was delayed for at least 1 min. MAIN OUTCOME MEASURES: Heart rate was recorded at 1 s intervals, and the 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles were calculated from 5 s to 5 min after birth. RESULTS: 898 newborns with a mean (SD) birth weight 3594 (478) g and gestational age 40 (1) weeks were included. The heart rate increased rapidly from median (IQR) 122 (98-146) to 168 (146-185) beats per minute (bpm) during the first 30 s after birth, peaking at 175 (157-189) bpm at 61 s after birth, and thereafter slowly decreasing. The third centile reached 100 bpm at 34 s, suggesting that heart rates <100 bpm during the first minutes after birth are uncommon in healthy newborns after delayed cord clamping. CONCLUSION: This report presents normal heart rate centiles from 5 s to 5 min after birth in healthy term newborns delivered vaginally with delayed cord clamping.

Comparison of Respiratory Support After Delivery in Infants Born Before 28 Weeks' Gestational Age: The CORSAD Randomized Clinical Trial.

Importance: Establishing stable breathing is a key event for preterm infants after birth. Delivery of pressure-stable continuous positive airway pressure and avoiding face mask use could be of importance in the delivery room. Objective: To determine whether using a new respiratory support system with low imposed work of breathing and short binasal prongs decreases delivery room intubations or death compared with a standard T-piece system with a face mask. Design, Setting, and Participants: In this unblinded randomized clinical trial, mothers threatening preterm delivery before week 28 of gestation were screened. A total of 365 mothers were enrolled, and 250 infants were randomized before birth and 246 liveborn infants were treated. The trial was conducted in 7 neonatal intensive care units in 5 European countries from March 2016 to May 2020. The follow-up period was 72 hours after intervention. Interventions: Infants were randomized to either the new respiratory support system with short binasal prongs (n = 124 infants) or the standard T-piece system with face mask (n = 122 infants). The intervention was providing continuous positive airway pressure for 10 to 30 minutes and positive pressure ventilation, if needed, with the randomized system. Main Outcomes and Measures: The primary outcome was delivery room intubation or death within 30 minutes of birth. Secondary outcomes included respiratory and safety variables. Results: Of 246 liveborn infants treated, the mean (SD) gestational age was 25.9 (1.3) weeks, and 127 (51.6%) were female. A total of 41 infants (33.1%) receiving the new respiratory support system were intubated or died in the delivery room compared with 55 infants (45.1%) receiving standard care. The adjusted odds ratio was statistically significant after adjusting for stratification variables (adjusted odds ratio, 0.53; 95% CI, 0.30-0.94; P = .03). No significant differences were seen in secondary outcomes or safety variables. Conclusions and Relevance: In this study, using the new respiratory support system reduced delivery room intubation in extremely preterm infants. Stabilizing preterm infants with a system that has low imposed work of breathing and binasal prongs as interface is safe and feasible. Trial Registration: ClinicalTrials.gov Identifier: NCT02563717.

Compliance with Guidelines and Efficacy of Heart Rate Monitoring during Newborn Resuscitation: A Prospective Video Study.

OBJECTIVE: Newborn resuscitation guidelines recommend initial assessment of heart rate (HR) and initiation of positive pressure ventilation (PPV) within 60 s after birth in non-breathing newborns. Pulse oximeter (PO) and electrocardiogram (ECG) are suggested methods for continuous HR monitoring during resuscitation. Our aim was to evaluate compliance with guidelines and the efficacy of PO versus ECG monitoring in real-life newborn resuscitations. METHODS: In this prospective observational study, we video recorded resuscitations of newborns ≥34 weeks of gestation receiving PPV at birth. RESULTS: 104 resuscitations were analysed. Median (IQR) time from birth to arrival at the resuscitation bay was 48 (22-68) s (n = 62), to initial HR assessment 70 (47-118) s (n = 61), and to initiation of PPV 78 (42-118) s (n = 62). Initial HR assessment (stethoscope or palpation) and initiation of PPV were achieved within 60 s for 35% of the resuscitated newborns. Time to initial HR assessment and initiating PPV was significantly longer following vaginal deliveries than caesarean sections: 84 (70-139) versus 44 (30-66) s (p < 0.001) and 93 (73-139) versus 38 (30-66) s (p < 0.001). Time from birth and sensor application to provision of a reliable HR signal from PO versus ECG was 348 (217-524) (n = 42) versus 174 (105-277) s (n = 30) (p < 0.001) and 199 (77-352) (n = 65) versus 16 (11-22) s (n = 52) (p < 0.001). CONCLUSION: Initial HR assessment and initiation of PPV were achieved within 60 s after birth in only 1/3 of newborn resuscitations. When applied for continuous HR monitoring, ECG was superior to PO in time to achieve reliable HR signals in real-life resuscitations.

Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study.

OBJECTIVES: To determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation. DESIGN SETTING AND PATIENTS: A prospective observational study in an unselected population at Stavanger University Hospital, Norway, from October 2016 until September 2017. INTERVENTIONS: Using a data collection form and video recordings, we registered and analysed resuscitative interventions. MAIN OUTCOME MEASURES: Incidence of continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), intubation, chest compressions and intravenous fluid or epinephrine boluses. Short-term outcomes of resuscitated newborns. RESULTS: All 4693 newborns in the study period were included in the study. Two hundred and ninety-one (6.2%) newborns received interventions in the first minutes of life beyond drying and stimulation. PPV was provided in 170 (3.6%) while CPAP (without PPV) was provided in 121 (2.6%) newborns. Duration of PPV was median (IQR) 106 s (54-221). Intubations were performed in 19 (0.4%) newborns, with a mean (SD) intubation time of 47 (21) s. Ten (0.2%) newborns received chest compressions and epinephrine was administrated in three (0.1%) newborns. Sixty-three per cent of the treated newborns from 34 weeks' gestational age were returned to parental care without further follow-up. CONCLUSIONS: The need for resuscitative interventions after birth was frequent in this unselected population in a high-resource setting, but full cardiopulmonary resuscitation was rare. Short-term outcomes were good, suggesting that most newborns treated with resuscitative interventions were not severely affected.