Am J Perinatol
DOI: 10.1055/a-1933-7235
Review Article

Providing Positive End-Expiratory Pressure during Neonatal Resuscitation: A Meta-analysis

Ioannis Bellos
1   Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Division of Surgery, Athens University Medical School, National and Kapodistrian University of Athens, Greece
,
Anish Pillai
2   Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
,
Aakash Pandita
3   Department of Neonatology, Medanta Hospital, Lucknow, Uttar Pradesh, India
› Author Affiliations
Funding None.

Abstract

Our objective was to conduct a systematic review and meta-analysis evaluating the effects of administering positive end-expiratory pressure (PEEP) during neonatal resuscitation at birth. Medline, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases were systematically searched from inception to 15 December 2020. Randomized controlled trials and cohort studies were held eligible. Studies were included if they compared the administration of PEEP using either a T-piece resuscitator or a self-inflating bag with a PEEP valve versus resuscitation via a self-inflating bag without a PEEP valve. Data were extracted by two reviewers independently. The credibility of evidence was appraised with the Grading of Recommendations, Assessment, Development, and Evaluations approach. Random-effects models were fitted to provide pooled estimates of risk ratio (RR) and 95% confidence intervals (CIs). Overall, 10 studies were included, comprising 4,268 neonates. This included five randomized controlled trials, one quasi-randomized trial, and four cohort studies. The administration of PEEP was associated with significantly lower rates of mortality till discharge (odds ratio [OR]: 0.60, 95% CI: 0.49–0.74, moderate quality of evidence). The association was significant in preterm (OR: 0.57, 95% CI: 0.46–0.69) but not in term (OR: 1.03, 95% CI: 0.52–2.02) neonates. Low-to-moderate quality evidence suggests that providing PEEP during neonatal resuscitation is associated with lower rates of mortality in preterm neonates. Evidence regarding term neonates is limited and inconclusive. Future research is needed to determine the optimal device and shed more light on the long-term effects of PEEP administration during neonatal resuscitation. This study is registered with PROSPERO with registration number: CRD42020219956.

Key Points

  • PEEP administration during neonatal resuscitation in the delivery room reduces mortality in preterm.

  • Evidence regarding term neonates is limited and inconclusive.

  • Future research is needed to determine the optimal device.

Data Availability Statement

All relevant data have been provided the manuscript. This study is registered with the Clinical Trial Registration (if any) with PROSPERO identifier: CRD42020219956.


Authors' Contributions

A.P. and I.B. conceptualized and designed the study, collected data, performed the initial analyses, and reviewed and revised the manuscript. A.P. wrote the initial manuscript and collected data. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.


Supplementary Material



Publication History

Received: 11 December 2021

Accepted: 12 August 2022

Accepted Manuscript online:
30 August 2022

Article published online:
09 November 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Associated clinical events. Arch Pediatr Adolesc Med 1995; 149 (01) 20-25
  • 2 Wall SN, Lee ACC, Niermeyer S. et al. Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up?. Int J Gynaecol Obstet 2009;107(1, suppl 1):S47–S62, S63–S64
  • 3 O'Donnell CPF, Davis PG, Morley CJ. Positive pressure ventilation at neonatal resuscitation: review of equipment and international survey of practice. Acta Paediatr 2004; 93 (05) 583-588
  • 4 Aziz K, Lee HC, Escobedo MB. et al. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142 (16_suppl_2): S524-S550
  • 5 Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation 2012; 83 (07) 869-873
  • 6 Stoll BJ, Hansen NI, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126 (03) 443-456
  • 7 O'Donnell CPF, Davis PG, Morley CJ. Use of supplementary equipment for resuscitation of newborn infants at tertiary perinatal centres in Australia and New Zealand. Acta Paediatr 2005; 94 (09) 1261-1265
  • 8 Donaldsson S, Drevhammar T, Li Y. et al; CORSAD Trial Investigators. Comparison of respiratory support after delivery in infants born before 28 weeks' gestational age: the CORSAD randomized clinical trial. JAMA Pediatr 2021; 175 (09) 911-918
  • 9 Björklund LJ, Ingimarsson J, Curstedt T. et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr Res 1997; 42 (03) 348-355
  • 10 Michna J, Jobe AH, Ikegami M. Positive end-expiratory pressure preserves surfactant function in preterm lambs. Am J Respir Crit Care Med 1999; 160 (02) 634-639
  • 11 Naik AS, Kallapur SG, Bachurski CJ. et al. Effects of ventilation with different positive end-expiratory pressures on cytokine expression in the preterm lamb lung. Am J Respir Crit Care Med 2001; 164 (03) 494-498
  • 12 Hussey SG, Ryan CA, Murphy BP. Comparison of three manual ventilation devices using an intubated mannequin. Arch Dis Child Fetal Neonatal Ed 2004; 89 (06) F490-F493
  • 13 Finer NN, Rich W, Craft A, Henderson C. Comparison of methods of bag and mask ventilation for neonatal resuscitation. Resuscitation 2001; 49 (03) 299-305
  • 14 Bennett S, Finer NN, Rich W, Vaucher Y. A comparison of three neonatal resuscitation devices. Resuscitation 2005; 67 (01) 113-118
  • 15 Tracy MB, Halliday R, Tracy SK, Hinder MK. Newborn self-inflating manual resuscitators: precision robotic testing of safety and reliability. Arch Dis Child Fetal Neonatal Ed 2019; 104 (04) F403-F408
  • 16 Hinder M, McEwan A, Drevhammer T, Donaldson S, Tracy MB. T-piece resuscitators: how do they compare?. Arch Dis Child Fetal Neonatal Ed 2019; 104 (02) F122-F127
  • 17 Hartung JC, Dold SK, Thio M, tePas A, Schmalisch G, Roehr CC. Time to adjust to changes in ventilation settings varies significantly between different T-piece resuscitators, self-inflating bags, and manometer equipped self-inflating bags. Am J Perinatol 2014; 31 (06) 505-512
  • 18 Wyllie J, Perlman JM, Kattwinkel J. et al; Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015; 95: e169-e201
  • 19 O'Donnell C, Davis P, Morley C. Positive end-expiratory pressure for resuscitation of newborn infants at birth. Cochrane Database Syst Rev 2004; (04) CD004341
  • 20 Roehr CC, Davis PG, Weiner GM, Jonathan Wyllie J, Wyckoff MH, Trevisanuto D. T-piece resuscitator or self-inflating bag during neonatal resuscitation: a scoping review. Pediatr Res 2021; 89 (04) 760-766
  • 21 Holte K, Ersdal H, Eilevstjønn J. et al. Positive end-expiratory pressure in newborn resuscitation around term: a randomized controlled trial. Pediatrics 2020; 146 (04) e20200494
  • 22 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
  • 23 Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM. Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics 1988; 82 (04) 527-532
  • 24 Greenhalgh T, Peacock R. Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. BMJ 2005; 331 (7524): 1064-1065
  • 25 Higgins JPT, Altman DG, Gøtzsche PC. et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
  • 26 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
  • 27 Balshem H, Helfand M, Schünemann HJ. et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011; 64 (04) 401-406
  • 28 Viechtbauer W. Conducting meta-analyses in R with the metafor Package. J Stat Softw 2010; 36: 1-48
  • 29 Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327 (7414): 557-560
  • 30 IntHout J, Ioannidis JP, Rovers MM, Goeman JJ. Plea for routinely presenting prediction intervals in meta-analysis. BMJ Open 2016; 6 (07) e010247
  • 31 Shi L, Lin L. The trim-and-fill method for publication bias: practical guidelines and recommendations based on a large database of meta-analyses. Medicine (Baltimore) 2019; 98 (23) e15987
  • 32 Ioannidis JPA, Trikalinos TA. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey. CMAJ 2007; 176 (08) 1091-1096
  • 33 Gomo ØH, Eilevstjønn J, Holte K, Yeconia A, Kidanto H, Ersdal HL. Delivery of positive end-expiratory pressure using self-inflating bags during newborn resuscitation is possible despite mask leak. Neonatology 2020; 117 (03) 341-348
  • 34 Schmölzer GM, Dawson JA, Kamlin COF, O'Donnell CPF, Morley CJ, Davis PG. Airway obstruction and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2011; 96 (04) F254-F257
  • 35 Klingenberg C, Dawson JA, Gerber A, Kamlin COF, Davis PG, Morley CJ. Sustained inflations: comparing three neonatal resuscitation devices. Neonatology 2011; 100 (01) 78-84
  • 36 Jeevan A, Balasubramanian H, Kabra N. Effect of T-piece resuscitator versus self inflating bag on arterial CO2 levels in preterm neonates. Indian J Pediatr 2020; 87 (11) 897-904
  • 37 Kookna S, Singh AK, Pandit S, Dhawan N. T-Piece Resuscitator or Self Inflating Bag for Positive Pressure Ventilation during Neonatal Resuscitation: A Randomized Controlled Trial. Accessed May 9, 2022 at: https://www.semanticscholar.org/paper/T-Piece-Resuscitator-or-Self-Inflating-Bag-for-A-kookna-Singh/591579d3378cce1c9284ad2b93bae1d35b5b4280
  • 38 Kitsommart 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 (05) 448-454
  • 39 Siripattanapipong P, Nakornchai K, Wutthigate P, Kitsommart R. Effectiveness of T-piece resuscitator versus self-inflating bag during birth resuscitation in very low birth weight infants. Southeast Asian J Trop Med Public Health 2017; 48: 7
  • 40 Guinsburg R, de Almeida MFB, de Castro JS. et al. T-piece versus self-inflating bag ventilation in preterm neonates at birth. Arch Dis Child Fetal Neonatal Ed 2018; 103 (01) F49-F55
  • 41 Thakur A, Saluja S, Modi M. et al. T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: an RCT. Resuscitation 2015; 90: 21-24
  • 42 Ng KF, Choo P, Paramasivam U, Soelar SA. Reduction of intubation rate during newborn resuscitation after transition from self-inflating bag to T-piece resuscitator. Med J Malaysia 2015; 70 (04) 228-231
  • 43 Szyld E, Aguilar A, Musante GA. et al; Delivery Room Ventilation Devices Trial Group. Comparison of devices for newborn ventilation in the delivery room. J Pediatr 2014; 165 (02) 234-239 .e3
  • 44 Jayaram A, Sima A, Barker G, Thacker LR. T-piece resuscitator versus self-inflating bag for preterm resuscitation: an institutional experience. Respir Care 2013; 58 (07) 1233-1236
  • 45 Dawson JA, Schmölzer GM, Kamlin COF. 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 (06) 912-918.e1 , 2