Prolonged lung inflation for neonatal resuscitation

Review question

Does the use of sustained (> one second duration) lung inflations compared to standard inflations (≤ one second) improve survival and other important outcomes in newly born infants receiving resuscitation at birth?

Background

At birth, human lungs are filled with fluid which must be replaced by air for infants to breathe properly. Some infants have difficulty in establishing effective breathing at birth and one in every 20 to 30 newborns receive help to do so. A variety of devices are used to help infants begin their normal breathing. Some of these devices allow the caregivers to give long (or sustained) inflations. These sustained inflations may help inflate the lungs and keep the lungs inflated better than if they are not used.

Study characteristics

We searched for all randomised and quasi-randomised controlled trials that studied sustained inflation compared to standard inflations in neonatal resuscitation up to 1 Febuary 2015. Two RCTs enrolling 352 infants met our inclusion criteria.

Results

The two included trials provided insufficient evidence to determine if the risk of death during hospitalisation, intubation in the first three days of life, or chronic lung disease are different between infants who received sustained versus standard inflations. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Several studies are ongoing.

Authors' conclusions: 

At present there is insufficient evidence from clinical trials to determine the efficacy and safety of initial sustained lung inflation for newborn infants resuscitated with PPV. RCTs comparing PPV with and without sustained inflations at neonatal resuscitation are warranted.

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Background: 

At birth, infants' lungs are fluid-filled; this fluid must be replaced by air to allow for effective breathing. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume in the lungs.

Objectives: 

To assess the efficacy of initial sustained (> one second duration) lung inflation compared to standard inflations (≤ one second) in newly born infants receiving resuscitation with intermittent PPV.

Search strategy: 

We searched on PubMed (1966 to 1 February 2015), EMBASE (1980 to 1 February 2015) and the Cochrane Central Register of Controlled Trials (the Cochrane Library 2015). No language restrictions were applied. We searched the abstracts of the Pediatric Academic Societies (PAS) from 2000 to 2014.

Selection criteria: 

Randomised controlled trials (RCTs) and quasi-RCTs comparing giving initial sustained lung inflations (SLI) vs. standard inflations to infants receiving resuscitation with PPV at birth.

Data collection and analysis: 

We assessed methodological quality of the included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up and handling of outcome data). We evaluated the treatment effect using a fixed-effect model using risk ratio for categorical data and using mean, standard deviation (SD) and weighted mean difference (WMD) for continuous data.

Main results: 

Two trials enrolling 352 infants met our inclusion criteria. There were no differences in the rates of mortality during hospitalisation (RR 1.59, 95% CI 0.81 to 3.10; two trials, 352 infants), intubation in the first three days of life (RR 0.85, 95% CI 0.72 to 1.02; two trials, 352 infants) or chronic lung disease (RR 1.06, 95% CI 0.79 to 1.42; two trials, 349 infants) between infants who received sustained versus standard inflations. The rate of patent ductus arteriosus (reported as need for pharmacological treatment) was higher in the sustained inflation group (RR 1.27, 95% CI 1.03 to 1.56; two trials, 352 infants).

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