Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room

Mian, Qaasim; Cheung, Po Yin; O’Reilly, Megan; Barton, Samantha K.; Polglase, Graeme R.; Schmölzer, Georg M.

doi:10.1136/archdischild-2017-313864

Cited by 58 publications

(42 citation statements)

References 52 publications

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“…We have demonstrated that not only high EtCO 2 levels during resuscitation in the delivery suite were associated with IVH development but also inflations resulting in larger tidal volumes and lower EtCO 2 levels [3]. Those findings were subsequently confirmed by Mian and colleagues who found that tidal volumes in excess of 6 ml/kg were associated with cerebral damage in the neonatal period [8]. A further aim, therefore, of this study then was to test the hypothesis that infants exposed to the largest fluctuations in EtCO 2 levels during resuscitation in the delivery suite would be at greatest risk of developing an IVH.…”

Section: Introductionsupporting

confidence: 54%

End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage

et al. 2019

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Abnormal levels of end-tidal carbon dioxide (EtCO 2 ) during resuscitation in the delivery suite are associated with intraventricular haemorrhage (IVH) development. Our aim was to determine whether carbon dioxide (CO 2 ) levels in the first 3 days after birth reflected abnormal EtCO 2 levels in the delivery suite, and hence, a prolonged rather than an early insult resulted in IVH. In addition, we determined if greater EtCO 2 level fluctuations during resuscitation occurred in infants who developed IVH. EtCO 2 levels during delivery suite resuscitation and CO 2 levels on the neonatal unit were evaluated in 58 infants (median gestational age 27.3 weeks). Delta EtCO 2 was the difference between the highest and lowest level of EtCO 2 . Thirteen infants developed a grade 3-4 IVH (severe group). There were no significant differences in CO 2 levels between those who did and did not develop an IVH (or severe IVH) on the NICU. The delta EtCO 2 during resuscitation differed between infants with any IVH (6.2 (5.4-7.5) kPa) or no .3) kPA) (p < 0.001) after adjusting for differences in gestational age. Delta EtCO 2 levels gave an area under the ROC curve of 0.940 for prediction of IVH.Conclusion: The results emphasize the importance of monitoring EtCO 2 levels in the delivery suite.

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Section: Introductionsupporting

confidence: 54%

End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage

et al. 2019

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“…Moreover, although several studies have demonstrated CC+SI can provide adequate V T , relatively high distending pressure may cause higher V T [18,31,32]. Therefore, clinicians should be aware of the V T used during PPV and deliver <6-8 mL/kg, particularly in very preterm infants [17,25,31]. In this study, the delivered V T was significantly greater in piglets resuscitated with CC+SI_PIP_30, shown to cause brain inflammation and injury in several animal studies [33][34][35].…”

Section: Discussionmentioning

confidence: 64%

“…Furthermore, a recent observational study in preterm infants <29 weeks' gestation observed a four-fold increase in intraventricular hemorrhage in infants ventilated even with a V T >6 mL/kg [17]. Taken together, these studies highlight the link between high V T delivery and the progression of brain injury.…”

Section: Discussionmentioning

confidence: 74%

“…There is evidence that a PIP of 20 to 25 cmH 2 O causes high tidal volume (V T ) delivery in preterm infants [13,14], and excessive V T delivery induced by high PIP may cause hypocarbia [15], which is associated with brain injury [16]. Recently, Mian et al observed that preterm infants <29 weeks' gestation who received mask PPV with V T >6 mL/kg have significantly higher rates of intraventricular hemorrhage [17]. However, to date no study has measured the optimal PIP and the adequate V T delivery during CC in the delivery room.…”

Section: Introductionmentioning

confidence: 99%

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Effects of sustained inflation pressure during neonatal cardiopulmonary resuscitation of asphyxiated piglets

Shim

Kim

Cheung

et al. 2020

Preprint

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ObjectiveSustained inflation (SI) during chest compression (CC = CC+SI) significantly reduces time to return of spontaneous circulation (ROSC) compared to 3:1 compression-to-ventilation ratio during neonatal resuscitation. However, the optimal peak inflation pressure (PIP) of SI during CC+SI to improve ROSC and hemodynamic recovery in severely asphyxiated piglets is unknown.AimTo examine if different PIPs of SI during CC+SI will improve ROSC and hemodynamic recovery in severely asphyxiated piglets.Intervention and measurementsTwenty-nine newborn piglets (1-3 days old) were anesthetized, intubated, instrumented and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into four groups: CC+SI with a PIP of 10 cmH2O (CC+SI_PIP_10, n=8), a PIP of 20 cmH2O (CC+SI_PIP_20, n=8), a PIP of 30 cmH2O (CC+SI_PIP_30, n=8), and a sham-operated control group (n=5). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.Main resultsBaseline parameters were similar between all groups. There was no difference in asphyxiation (duration and degree) between intervention groups. PIP correlated positively with tidal volume and inversely with exhaled CO2 during cardiopulmonary resuscitation. Time to ROSC and rate of ROSC were similar between piglets resuscitated with CC+SI_PIP_10, CC+SI_PIP_20, and CC+SI_PIP_30 cmH2O: median (IQR) 75 (63-193) sec, 94 (78-210) sec, and 85 (70-90) sec; 5/8 (63%), 7/8 (88%), and 3/8 (38%) (p=0.56 and p=0.12, respectively). All piglets that achieved ROSC survived to four hours post-resuscitation. Piglets resuscitated with CC+SI_PIP_30 cmH2O exhibited increased concentrations of pro-inflammatory cytokines interleukin-1β and tumour necrosis factor-α in the frontoparietal cerebral cortex (both p<0.05 vs. sham-operated controls).ConclusionsIn asphyxiated term newborn piglets resuscitated by CC+SI, the use of different PIPs resulted in similar time to ROSC, but PIP at 30 cmH2O showed a larger VT delivery, lower exhaled CO2 and increased tissue inflammatory markers in the brain.

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“…Preclinical studies showed that high tidal volumes adversely affect the cardiopulmonary haemodynamics and even can cause lung27 28 and brain injury 6 29. A recent clinical study30 confirmed the danger of high tidal volumes, as they found more intraventricular haemorrhages in infants receiving tidal volumes >6 mL/kg.…”

Section: Cpap or Ppv Via Facemask When Breathing Is Insufficient In Vmentioning

confidence: 86%

Supporting breathing of preterm infants at birth: a narrative review

Martherus

Oberthuer

Dekker

et al. 2018

Arch Dis Child Fetal Neonatal Ed

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Most very preterm infants have difficulty aerating their lungs and require respiratory support at birth. Currently in clinical practice, non-invasive ventilation in the form of continuous positive airway pressure (CPAP) and positive pressure ventilation (PPV) is applied via facemask. As most very preterm infants breathe weakly and unnoticed at birth, PPV is often administered. PPV is, however, frequently ineffective due to pressure settings, mask leak and airway obstruction. Meanwhile, high positive inspiratory pressures and spontaneous breathing coinciding with inflations can generate high tidal volumes. Evidence from preclinical studies demonstrates that high tidal volumes can be injurious to the lungs and brains of premature newborns. To reduce the need for PPV in the delivery room, it should be considered to optimise spontaneous breathing with CPAP. CPAP is recommended in guidelines and commonly used in the delivery room after a period of PPV, but little data is available on the ideal CPAP strategy and CPAP delivering devices and interfaces used in the delivery room. This narrative review summarises the currently available evidence for why PPV can be inadequate at birth and what is known about different CPAP strategies, devices and interfaces used the delivery room.

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Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room

Abstract: High V delivery during mask PPV at birth was associated with brain injury. Strategies to limit V delivery during mask PPV should be used to prevent high V delivery.

Cited by 58 publications

References 52 publications

End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage

End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage

Effects of sustained inflation pressure during neonatal cardiopulmonary resuscitation of asphyxiated piglets

Supporting breathing of preterm infants at birth: a narrative review

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