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