Positive end-expiratory pressure during resuscitation at birth in very-low-birth-weight infants: A randomized controlled pilot trial
2018; Elsevier BV; Volume: 59; Issue: 5 Linguagem: Inglês
10.1016/j.pedneo.2018.09.002
ISSN2212-1692
Autores Tópico(s)Respiratory Support and Mechanisms
ResumoVery-low-birth-weight (VLBW) premature infants show a high risk of developing surfactant deficiency, respiratory difficulty, or apnea after birth. The neonatal resuscitation guideline recommends resuscitation in the delivery room by positive pressure ventilation (PPV) to rescue high-risk newborns suffering from apnea, gasping, or a heart rate of less than 100/min.1Perlman J.M. Wyllie J. Kattwinkel J. Wyckoff M.H. Aziz K. Guinsburg R. et al.Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.Circulation. 2015; 132: S204-S241Crossref PubMed Scopus (440) Google Scholar, 2Wyckoff M.H. Aziz K. Escobedo M.B. Kapadia V.S. Kattwinkel J. Perlman J.M. et al.Part 13: neonatal resuscitation: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2015; 132: S543-S560Crossref PubMed Scopus (529) Google Scholar Positive end-expiratory pressure (PEEP) using 5 cm H2O is recommended while applying PPV in neonatal resuscitation; however, there is still a lack of strong evidence of the beneficial significance of PEEP in VLBW infants through clinically randomized controlled trials. In neonatal resuscitation, self-inflating bags (SIBs) with or without PEEP assembly, flow-inflating bags, or T-piece resuscitators (TPRs) (Neopuff, Fisher and Paykel Healthcare, Auckland, New Zealand) are commonly used for providing PPV. In an earlier study, Dawson et al. (2011)3Dawson J.A. Schmölzer G.M. Kamlin C.O. Te Pas A.B. O'Donnell C.P. Donath S.M. et al.Oxygenation with T-piece versus self-inflating bag for ventilation of extremely preterm infants at birth: a randomized controlled trial.J Pediatr. 2011; 158 (e1–2): 912-918Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar randomized infants of < 29 weeks of gestation to receive PPV by TPRs (PEEP = 5 cm H2O) or SIBs (no PEEP valve) and demonstrated no significant difference in mortality, requirement of endotracheal intubation, need for respiratory supports at the age of 28 days, and oxygen saturation or heart rate at 5 min after birth between the two study groups. In a review of 30 studies by Hawkes et al. (2012),4Hawkes C.P. Ryan C.A. Dempsey E.M. Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: a qualitative review.Resuscitation. 2012; 83: 797-802Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar the authors mentioned that only two randomized controlled trials had compared the devices and reported no significant difference between the use of TPRs and SIBs. They concluded that more well-designed randomized controlled trials must be performed for confirmingthe efficacy of these devices in neonates.4Hawkes C.P. Ryan C.A. Dempsey E.M. Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: a qualitative review.Resuscitation. 2012; 83: 797-802Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In a multicenter trial conducted by Szyld et al. (2014),5Szyld E. Aguilar A. Musante G.A. Vain N. Prudent L. Fabres J. et al.Comparison of devices for newborn ventilation in the delivery room.J Pediatr. 2014; 165 (e3): 234-239Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar no significant difference was observed between the use of TPRs (PEEP = 5 cm H2O) and SIBs (PEEP = 5 or 0 cm H2O) in achieving heart rates of ≥ 100 bpm at 2 min in newborns of ≥ 26 weeks of gestation. However, their results demonstrated that the use of TPRs decreased the intubation rate and the maximum pressures applied.5Szyld E. Aguilar A. Musante G.A. Vain N. Prudent L. Fabres J. et al.Comparison of devices for newborn ventilation in the delivery room.J Pediatr. 2014; 165 (e3): 234-239Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Thus, TPRs were considered to provide PEEP more effectively than SIBs using a PEEP valve to establish an effective functional residual capacity in newborn infants. In the report of the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations,2Wyckoff M.H. Aziz K. Escobedo M.B. Kapadia V.S. Kattwinkel J. Perlman J.M. et al.Part 13: neonatal resuscitation: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2015; 132: S543-S560Crossref PubMed Scopus (529) Google Scholar PEEP was evaluated again, and the committee mentioned the trial conducted by Szyld et al. (2014)5Szyld E. Aguilar A. Musante G.A. Vain N. Prudent L. Fabres J. et al.Comparison of devices for newborn ventilation in the delivery room.J Pediatr. 2014; 165 (e3): 234-239Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar for their evidence that the maximum amount of supplementary oxygen required to achieve the target oxygen saturation was slightly less while using PEEP. Therefore, the 2010 recommendation was repeated as follows: when PPV is administered to preterm newborns, the use of approximately 5 cm H2O PEEP is suggested (Class IIb).2Wyckoff M.H. Aziz K. Escobedo M.B. Kapadia V.S. Kattwinkel J. Perlman J.M. et al.Part 13: neonatal resuscitation: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2015; 132: S543-S560Crossref PubMed Scopus (529) Google Scholar Later, Thakur et al. (2015)6Thakur A. Saluja S. Modi M. Kler N. Garg P. Soni A. et al.T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: an RCT.Resuscitation. 2015; 90: 21-24Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar compared the use of TPRs (PEEP = 5 cm H2O) with SIBs (no PEEP valve) in neonates of > 26 weeks of gestation requiring PPV at birth. They reported shorter duration of PPV and lesser rates of intubation in the TPR group than in the SIB group. The authors also demonstrated that more infants in the TPR group could be resuscitated successfully using room air alone.6Thakur A. Saluja S. Modi M. Kler N. Garg P. Soni A. et al.T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: an RCT.Resuscitation. 2015; 90: 21-24Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Recently, Guinsburg et al. (2018) published a multicenter trial involving 714 VLBW premature infants who received PPV in the delivery room using TPRs (PEEP = 5 cm H2O) or SIBs (no PEEP valve). They demonstrated that TPRs increased the chance of survival to discharge without bronchopulmonary dysplasia, severe intraventricular hemorrhage, or periventricular leukomalacia. This was also associated with an increased chance of a 5-min Apgar score of ≥ 7.7Guinsburg R. de Almeida M.F.B. de Castro J.S. Gonçalves-Ferri W.A. Marques P.F. Caldas J.P.S. et al.T-piece versus self-inflating bag ventilation in preterm neonates at birth.Arch Dis Child Fetal Neonatal Ed. 2018; 103: F49-F55Crossref PubMed Scopus (33) Google Scholar Therefore, the use of TPRs with PEEP of 5 cm H2O appears to be beneficial in VLBW infants. Nevertheless, the majority of these published reports compared different devices, which may influence the results. In the pilot trial conducted by Kitsommart et al. (published online in 2017),8Kitsommart R. Nakornchai K. Yangthara B. Jiraprasertwong R. Paes B. Positive end-expiratory pressure during resuscitation at birth in very-low birth weight infants: a randomized-controlled pilot trial.Pediatr Neonatol. 2018; 59: 448-454Abstract Full Text Full Text PDF Scopus (3) Google Scholar the authors investigated the role of PEEP (5 and 0 cm H2O) using the same TPR in premature neonates of < 32 weeks of gestation or weighing < 1500 g at birth for resuscitation by PPV in the delivery room. Although the pilot trial enrolled only 51 infants, it was the first report using the same device to compare the efficacy of PEEP in neonatal resuscitation.8Kitsommart R. Nakornchai K. Yangthara B. Jiraprasertwong R. Paes B. Positive end-expiratory pressure during resuscitation at birth in very-low birth weight infants: a randomized-controlled pilot trial.Pediatr Neonatol. 2018; 59: 448-454Abstract Full Text Full Text PDF Scopus (3) Google Scholar However, because of the small sample size and the potential bias due to lower birth weights in the PEEP-0 group, the results did not demonstrate differences in outcomes between the PEEP-5 and PEEP-0 groups.8Kitsommart R. Nakornchai K. Yangthara B. Jiraprasertwong R. Paes B. Positive end-expiratory pressure during resuscitation at birth in very-low birth weight infants: a randomized-controlled pilot trial.Pediatr Neonatol. 2018; 59: 448-454Abstract Full Text Full Text PDF Scopus (3) Google Scholar Further clinical trials with a larger sample size may provide significant evidence for confirming the safety and efficacy of postnatal PEEP while resuscitating VLBW premature infants in the delivery room. None.
Referência(s)