Elsevier

Resuscitation

Volume 156, November 2020, Pages 244-250
Resuscitation

Review
Interfaces for non-invasive neonatal resuscitation in the delivery room: A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2020.08.008Get rights and content

Abstract

Objective

To perform a systematic review of trials comparing interfaces for delivering non-invasive PPV to a newborn in the delivery room (DR).

Methods

MEDLINE, PUBMED, EMBASE, CINAHL and COCHRANE databases were searched on March 1, 2020 and 2826 articles were screened. The review was conducted using the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary outcomes were intubation in the DR and mortality. Secondary outcomes were chest compressions, intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC) and mask leak.

Results

Five randomized-control trials were eligible for inclusion. Sample size and gestational age varied amongst the trials, ranging from 56 to 617 infants and 24–39 weeks’ respectively. Three trials compared nasal cannulae (NC) with face masks (FMs). Pooled analysis showed that NC were associated with a decreased use of chest compressions (RR 0.2 (95% CI 0.08–0.47). A reduction in rate of intubation in the DR was statistically significant only in the trial in which bi-nasal rather than single nasal cannulae were used (RR 0.10, 95% CI 0.02−0.44). However, there was no important difference in mortality (RR 0.72, 95% CI 0.47–1.13). Two trials compared different FM models (Laerdal versus Fisher & Paykel and Laerdal versus Resusi-sure) and both found no significant difference in primary and secondary outcomes.

Conclusion

There is little high-quality evidence to guide clinicians choosing an interface to provide PPV during newborn resuscitation. Nasal interfaces, particularly binasal cannulae, appear to offer some advantages over FMs but need further testing in larger, well designed trials.

Study registration

PROSPERO CRD42020151870.

Introduction

Respiratory depression is common at birth and approximately 5% of newborns receive respiratory support during transition to extrauterine life.1 Birth asphyxia is associated with poor outcomes including hypoxic ischaemic encephalopathy (HIE) and death.1 Effective resuscitation may reduce the risk of these outcomes.1, 2 The International Liaison Committee on Resuscitation (ILCOR) recommends that positive pressure ventilation (PPV) is administered to apnoeic or bradycardic newborns.1 Delivering effective PPV is challenging.3 The operator’s technique, the interface and the infant’s facial features all influence effectiveness.4, 5 Common problems during resuscitation include mask leak6 and airway obstruction.7

International guidelines recommend that infants should receive initial PPV via a face-mask.8 There are a large variety of face masks available, differing in form, dimension, material and rim (Supplementary Table 1). There are two main shapes of face masks; round and anatomical (Fig. 1). Most currently available masks are round. There is variety in form (dome or flat top) and size, with diameters ranging from 35 to 60 mm.9 Current models are made with soft silicon whereas older masks consist of firm rubber. Types of rims available include single, double, inward curved circular flap or inflatable. The importance of creating an adequate seal between the mask and face is well established.10 However, this is technically difficult, even for experienced operators.11 Clinicians often fail to recognise the presence of large leaks during face mask ventilation.8, 12 Application of face masks may also induce apnoea through stimulation of the trigeminal nerve reflex, particularly in premature infants.13

Recent trials have investigated the use of nasal cannulae as an alternative interface for resuscitation.1, 14, 15 Providing PPV through nasal cannulae may avoid triggering apnoea via the trigeminal nerve reflex, and encourage spontaneous respirations.13 Due to the large variety of interfaces available, synthesis of the available evidence may aid clinicians to choose appropriate resuscitation equipment, optimise resuscitation of newborns and inform future research.

Section snippets

Objective

We conducted a systematic review of the literature to determine the most effective interface for delivering non-invasive PPV to a newborn in the DR.

Search strategy

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).16 The study was prospectively registered with a systematic review registry, PROSPERO (CRD42020151870). Relevant articles were identified through a systematic search of five electronic databases: MEDLINE, PUBMED, EMBASE, CINAHL, and COCHRANE. The search strategy used for all databases was developed using MESH terms and keywords: Infant, newborn

Study and data selection

The electronic search was last updated on March 1, 2020 and identified 5169 articles (Fig. 2). Three additional articles were identified from the reference lists of reviewed articles. After duplicates were removed, 2826 articles were screened for eligibility and 2787 articles were removed based on titles and abstracts. The remaining 39 full text articles were reviewed, of which 5 were included. 34 articles were excluded; not published in English (n = 8), non-randomised study design (n = 13),

Discussion

This systematic review highlights the lack of high-quality evidence to support a specific interface as most effective in providing PPV during newborn resuscitation. We identified five randomised control trials (RCTs) eligible for inclusion. The gestational age of the populations studied varied, three RCTs included preterm infants only and two included both term and preterm infants. Three RCTs compared a face mask to a nasal interface, two studies compared different face masks.

Pooled analysis

Limitations

Many of the available masks have not been evaluated in clinical trials. Studies included in this review were small and of variable quality. Caregivers and outcome assessors in each trial were not blinded, increasing the risk of bias. However, it is impossible to blind caregivers during resuscitation.

Conclusion

Despite the importance of adequate resuscitation in reducing neonatal morbidity and mortality and the large number of interfaces available to clinicians, few randomised controlled trials of interfaces to provide PPV have been conducted. Populations, interfaces and outcomes of trials are heterogenous. Therefore, it is difficult to make definite conclusions. Nasal interfaces, particularly binasal cannulae, appear to offer some advantages over face masks but need further testing in larger, well

Authors’ contributions

Smitha Machumpurath — Literature search, study design, data analysis, interpretation & writing.

Jennifer Dawson — Literature search, study design, data analysis, interpretation & editing.

Eoin O’Currain — Literature search, study design, data analysis, interpretation & editing.

Peter Davis — Literature search, study design, data analysis, interpretation & editing

Funding

Australian Government National Health and Medical Research Council (NHMRC) funding for Prof Peter G. Davis (App ID 1059111); NHMRC Program Grant 2017–2021 (App ID 1113902) for Prof Peter G. Davis, Dr Jennifer A. Dawson.

Ethics approval

No ethics approval was required for this review.

Disclosures

The authors report no conflicts of interest.

Conflict of interest statements

No conflicts of interest.

CRediT authorship contribution statement

Smitha Machumpurath: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing - original draft, Writing - review & editing. Eoin O’Currain: Conceptualization, Supervision, Writing - review & editing. Jennifer A. Dawson: Conceptualization, Supervision, Writing - review & editing. Peter G. Davis: Conceptualization, Supervision, Writing - review & editing.

Acknowledgement

Not applicable.

References (26)

  • M.H. Wyckoff et al.

    Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

    Circulation

    (2015)
  • J.E. O’Shea et al.

    Measurements from preterm infants to guide face mask size

    Arch Dis Child Fetal Neonatal Ed

    (2016)
  • F.E. Wood et al.

    Assessing the effectiveness of two round neonatal resuscitation masks: study 1

    Arch Dis Child Fetal Neonatal Ed

    (2008)
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