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Recent eLetters

Displaying 1-10 letters out of 609 published

  1. Re: Current debate about the limit of viability: the neglected majority

    Neonatal mortality in poor countries

    We appreciate Dr. Berger's astute observation that most of the babies in the world do not have access to neonatal intensive care. His statistics underestimate the extent of the problem. Around the world, 7 million infants die each year. Most die of diseases that are preventable or treatable. Their deaths are due to lack of access to the most basic medical care. This is not unique to premature babies. Most health outcomes are better in wealthier countries. This is a serious problem of distributice justice.

    We would suggest, however, that resource allocation decisions in both poor countries and rich consistently favor adults and older children over neonates. The systematic devaluation of neonates, prevalent in high- income countries, also exists in emerging economies. For example, the Disease Control Priorities Project, an ongoing effort to produce evidence- based analysis and resource materials to inform health policymaking in developing countries, suggests that the death of a 20 year old is worse than the death of a neonate: "An individual life acquires value only as it acquired self-awareness [...] an individual life acquired value as it develop bonds with others." An Institute of Medicine (1985) review of vaccine development priorities judged that the prevention of a death at age 20 should be valued at about two times the value of preventing an infant death. Some studies suggest that the lives of older people are worth three or four times the value of the life of a baby.

    Our comment focused on the data from a study of NICU decisions in France. We suspect that we would find a parallel phenomenon at a different point on the cost/age curve in lower income countries. It seems unlikely to us that the solution to infant mortality in poorer countries is to let more babies die in richer countries. Instead, the solution is to insist that, throughout the world, babies' lives should be valued as highly as those of adults and older children.

    1. Jamison DT, Shahid-Salles SA, Jamison J, Lawn JE Zupan J. Incorporating deaths near the time of birth into estimates of the global burden of disease. In Jamison DT, et al (Editors) Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): World Bank; 2006.

    2. Institute of Medicine. Committee on Issuees PfNVD. Division of Health Promotion and Disease Prevention. New Vaccine Development: Establishing Priorities. The National Academies Press, Washington, DC. 1985.

    3. Johannesson M, Johansson PO. Is the valuation of a QALY gained independent of age? Some empirical evidence. J Health Econ. 1997 Oct;16(5):589-99

    Conflict of Interest:

    None declared

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  2. Current debate about the limit of viability: the neglected majority

    It is with great interest that I read the editorial entitled "Delivery room practices for extremely preterm infants: the harms of the gestational age label" by Janvier and Lantos (1) analysing the results of the EPIPAGE-2 study (2). The two authors question the appropriateness of the French non-intervention approach towards infants born at 22, 23 and 24 weeks for whom NICU admission was withheld in 96%, 91% and 38% of cases, respectively. They emphasise that such policies do not just reflect outcomes, but also shape them. In addition, they highlight that three common arguments for non-intervention policies are severely flawed: treatment of extremely preterm infants is neither futile nor too expensive, and the majority of survivors are not disabled. They conclude that taking life and death decisions based on 7-day-periods of gestational age is scientifically flawed and ethically questionable.

    While I agree with their arguments for industrialised countries in principle, I feel uncomfortable when I consider them from a global perspective. In 2015, an estimated 2.8 million neonates died worldwide; 99% of these deaths occurred in low- and middle-income countries (LMICs) (3). In these countries, the vast majority of infants born at less than 28 -30 weeks' gestation die: this means that the limit of viability for most neonates who are born prematurely is at least six weeks above the limit discussed by the editorialists. Even for more mature infants with respiratory distress, birth asphyxia or infection the prognosis is grim in most LMICs. In this context, Janvier's and Lantos' view that "treatment of neonates born at 22 and 23 weeks is clearly not futile" appears flawed. Most of published research in neonatology focuses on improving outcome of neonates born in industrialised countries. Neglecting the fate of the majority of neonates born worldwide is what is truly ethically questionable.

    Thomas M. Berger Neonatal and Paediatric Intensive Care Unit Children's Hospital of Lucerne Lucerne, Switzerland

    1. Janvier A, Lantos J. Delivery room practices for extremely preterm infants: the harms of the gestational age label. Arch Dis Child Fetal Neonatal Ed Online First, published on April 8, 2016

    2. Parlbarg J, Ancel PY, Koshnod B, et al. Delivery room management of extremely preterm infants: the EPIPAGE-2 study. Arch Dis Child Fetal Neonatal Ed 2016 Feb 2, 2016 [Epub ahead of print]

    3. Statistics Division of the United Nations Department of Economic and Social Affairs. The millennium development goals report 2015. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf (accessed May 7, 2016)

    Conflict of Interest:

    None declared

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  3. Water births: adverse events for the baby are rare but devastating

    The overall tone of this systematic review is to reassure the reader that waterbirths are safe; this is not justified by the results which rely almost exclusively on extremely poor quality retrospective cohort studies. Different study designs have significant differences in their susceptibility to bias and the authors have largely ignored this issue. Larger, non-randomised studies, more prone to bias, carry more weight ; no meta-analysis should have been done with these data.

    In contrast to the use of immersion in the first stage of labour, waterbirth confers no benefit to the mother or baby and puts the baby at unacceptable risk; current trials are too small to rule this out. Adverse events for the baby are rare but devastating. A hypoxic-ischaemic fetus will aspirate water when gasping while immersed.

    The authors have deemed that a large, prospective, cohort study is an acceptable approach to determining the benefit/harm ratio for waterbirth. Such non-randomised studies are prone to significant bias. The control group would be fundamentally different to the waterbirth group, and such differences would undermine the major principle that both groups should be as similar as possible with respect all other factors that may be related to treatment and outcomes except for the intervention. With non-random assignment in a cohort study, equally eligible women with different risks for adverse outcomes will be assigned the intervention group (consciously or unconsciously) based on how the women themselves or their caregivers perceive the risk of adverse outcome -large numbers of women enrolled in this way will seriously imbalance the treatment groups with regard to factors affecting outcomes.

    An appropriately sized, good quality RCT with longterm follow-up remains the only reliable way to assess both the efficacy and the safety of waterbirths.

    Conflict of Interest:

    I was a peer reviewer for this paper.

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  4. Staffing in NICUs is more that a 1:1 nurse to patient ratio

    I read the article by Watson et al and the accompanying Editorial. While it is an interesting concept to link nurse patient ratios with mortality this does not take into account the individual nurses and their experiences. I would challenge the authors to demonstrate how retrospective data measures acuity and nursing experience. The authors presented the 1:1 ratio as measured by the percentage of ICU days where there was one nurse per patient. Realistically each patient has a different level of acuity and this will determine the nurse to patient ratio. However even with a one to one ratio each nurse also has a different level of experience. With the critical shortage of nurses in acute care areas in both the UK and Australia the practice is to recruit less experienced nurses and many NICUs take first year nurse graduates. How these nurses are supported and supervised to provide a level of safe practice would be a more meaningful measure to link with mortality or indeed morbidity in this vulnerable patient population.. If there is inadequate supervision from senior nurses or clinical nurse educators then the novice nurses learn from each other, indeed an unsafe practice. Perhaps a more useful measure would be for researchers to assist clinicians in auditing practices so we know what is actually being practiced and then look at morbidity and mortality as an outcome. As an experienced neonatal nurse I would challenge researchers that mortality is not a reliable measure of nursing work - we need to develop a set of outcome measures that are meaningful measures of nursing work in the NICU. By clinicians and researchers working together we can then strive to ensure the NICU is a safe environment and we would have measures to improve practice and outcomes for the infants and their families.

    Conflict of Interest:

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  5. The Dr Isaac 'Harry' Gosset Collection

    The 'Dr Isaac 'Harry' Gosset Collection' a repository of UK General Paediatric and Premature Baby Care 1947-1965 is now on line.

    http://www.northamptongeneral.nhs.uk/AboutUs/Ourhistory/Dr-Gosset/The -Dr-Isaac-Harry-Gosset-Collection.aspx

    Conflict of Interest:

    I am the author of the paper I am replying to

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  6. End of Life Decisions - Do we make them wisely?

    Hellman, Knigthon et Al and Carter in the accompanying editorial raise many issues dealing with the end of life care of sick newborn babies. Although consensus within multidisciplinary teams in each centre is recorded as being achieved relatively easily, the wide variation between centres in how each deals with the issue of withholding life saving treatments, particularly where there are 'quality of life issues' underscores a wider lack of consensus amongst practicing neonatologists.

    This raises a number of issues. The most challenging of which is why, when there is such variation between units is there such agreement within them? This could be because like-minded people work together, or more likely people who work together become like minded. More disturbingly, it raises the possibility that the consensus may not be as great as perceived with particularly junior members of the decision making team- perhaps even the parents- feeling unable to voice dissent.

    A further issue is the weight given to medical opinion in making ethical and moral judgements. In common with most doctors, I received little or no formal training in ethics. I can use technical language to make my forthright opinions sound ethical, but in an era increasingly asking for evidence I have little to back these up. Historically the medical profession has not always cloaked itself in glory when trying to play society's moral arbiter. We can often lapse into a language of certainty and authority which makes it difficult for others to challenge our positions.

    I have another difficult personal issue, which being late to the table I have only just realised. In common with most doctors of my generation I was not encouraged to think about why I do what I do. I see that there are many different types of doctors, many of us in hospital seem to be 'fixing' doctors in that we see ourselves as people that make problems better. If we could cope with uncertainty and some degree of failure we may be in different specialties. Patients that will not or cannot be fixed can challenge me as a doctor and make me feel in some way 'undermined.' In these situations I worry that decisions that I make or recommend may be as much for my benefit as they are for my patients or their family. As a 'fixer' it is easier to discard rather than live with broken things. These are incredibly complex feelings to acknowledge but they certainly do exist.

    The obvious solution, as is available in much of North America and other countries in the world would be to establish Ethics panels who could judge these matters. These could be hospital based, regional or supra regional and would include members with proper training in Ethics and legal knowledge. Undoubtedly their deliberations would be heavily informed by medical evidence and input, in much the same way that medical input informs but does not make, safeguarding decisions which are ultimately in the gifts of the courts and their agents. This would provide safeguards for patients, families and the medical teams who look after them.

    Conflict of Interest:

    None declared

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  7. Incostintencies in defining "Work of breathing"

    We read with great interest the recent article by Shetty et al (Arch Dis Child Fetal Neonatal Ed 2016;0:F1-F4) who showed that continuous positive airway pressure (CPAP) and humidified high-flow nasal cannula (HHFNC) in infants with evolving or established bronchopulmonary dysplasia (BPD) have similar effects on work of breathing (WOB).1 Like many other articles in this field, Shetty's paper unfortunately suffers from inconsistencies in defining WOB, which we wish to clarify. The definition "WOB" used throughout the paper, as a proxy for respiratory effort, seems misleading insofar Shetty et al actually assessed not WOB but the pressure time product (PTP) of the diaphragm (PTPdi). WOB and PTP, expressed either as esophageal pressure PTP or PTPdi, are two independent physical variables that address distinctly different features related to respiratory effort. In physics, the term "WOB" refers to the work done during each respiratory cycle and is mathematically expressed as WOB = ? Ppl x dVt. The Campbell diagram depicts the dynamic relationship between these two variables.2 In respiratory physiology, WOB describes the energy required as inspiratory flow begins to perform the task of ventilation. The term WOB might therefore be inaccurate to indicate the actual effort necessary for the patient to breathe, because it overlooks the energy expended during the isometric phase of respiration (muscle contraction without volume displacement). More properly, Shetty et al determined PTP, a variable that directly measures energy expenditure during the dynamic and isometric respiratory phases. PTP comprises the average inspiratory pressure starting from the onset of respiratory effort and the end of inspiration (Pavg): PTP = Pavg ? Ti.3 Because research into respiratory mechanics in spontaneously breathing infants is an exciting new field of study that increasingly attracts students, researchers, and physicians we need a concerted effort to clarify terminology that they might find confusing. Especially confusing is the tendency to use WOB as a proxy for respiratory effort when the variable measured is actually PTP. To prevent further confusion, we suggest defining respiratory effort in a consistent manner, keeping WOB and PTP as the variables for quantifying it physically. We hope that the research community will support this proposal and look forward to reading articles that put it into practice. Paola Papoff, MD Fabio Midulla, MD Francesco Montecchia, PhD References 1) Shetty S, Hickey A, Rafferty GF, et al. Work of breathing during CPAP and heated humidified high-flow nasal cannula. Arch Dis Child Fetal Neonatal Ed 2016; 0:F1-F4. 2) Cabello B, Mancebo J. Work of breathing. Intensive Care Med 2006;32:1311-4. 3) Grinnan DC1, Truwit JD. Clinical review: respiratory mechanics in spontaneous and assisted ventilation. Crit Care 2005;9:472-84.

    Conflict of Interest:

    None declared

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  8. Re: The reliability and safety of self-inflating bags for PIP/ PEEP delivery to neonates is all but clear

    Title: Reliance on manikin and bench studies of manual infant resuscitators: the devil is in the detail

    Dear Sirs

    Thank you for the opportunity to respond to Dr Roehr and colleagues' comments on our paper1. Our results in contrast to those of Morley2 and Kelm3 show consistent measured levels of PEEP close to the set values1.

    We feel an important detail has been overlooked in ignoring the manufacturers' product inserts which clearly state that using a third- party component should only be done with specific verification from the other manufacturer. More importantly the clip on expiratory diverter needed to attach any PEEP valve to the Laerdal SIB is prone to leak, this is stated in the product insert (Laerdal Product insert for SIB 4492 rev F). The performance of a Laerdal or third party PEEP valve connected to a Laerdal expiration diverter attached to a Laerdal SIB highlights the possibility of significant measurement bias which may have been present in the studies by Morley2 and Dawson4 In particular, the study by Kelm3 and colleagues who used 10 Ambu PEEP valves which used Laerdal expiratory diverter attached to the Laerdal SIB. The Laerdal SIB product insert warns that using a third-party device that is not verified may affect the performance of the Laerdal SIB.

    Ambu, in their product insert for their PEEP valves (10 and 20) state clearly that "for adjustment of PEEP valve a pressure manometer should be connected to the breathing system for monitoring of the adjustment" and advise increasing PEEP during ventilation to minimum required level. This is because the pressure marks on the PEEP valve are approximate only and must be adjusted with the aid of a manometer to provide the level of PEEP required. We followed the recommended Ambu procedure by using the Ambu disposable manometer to adjust the PEEP prior to study assessment of the Ambu PEEP valve 1. The studies cited by Dr Roehr appeared to simply rely on the PEEP valve pressure marks. Kelm et al (2009) 3 commented that the manufacturer, Ambu, advised them they should use a manometer connected to the SIB and that further studies should evaluate this improved system. The subsequent studies examining Ambu PEEP valves have not detailed use of manometers to adjust desired PEEP.5-7 One study has examined a single Ambu PEEP valve connected to an Ambu Mark IV SIB with Ambu manometer with primary aim of examining time to alter peak inflation pressures. Interesting, this study comparing SIB and two different T-piece resuscitators showed the Ambu SIB with manometer best targeted the PEEP levels which reflects the results of our larger more systematic examination of 6 different Ambu valves1.

    We do agree with Dr Roehr's comments regarding the advantage of in vitro studies having leak free models and the fact that recommendations based on these laboratory data should be made with considerable caution. In fully detailing the methodology used in determining system leak we have ensured a level of accuracy in our test results1 that we feel others should replicate. We state the use of static pressurisation to 50 cmH2O for 2 minutes with no fall in pressure to assert the absence of leak in measurement system.

    The important study by Dr Hishikawa8 and colleagues demonstrating an increase in term air-leak following the introduction of mask CPAP used "a flow-inflating bag with flow-control valve and pressure manometer" the "Hyperinflation Bag" by Mercury Medical Florida (http://mercurymed.com/pdf/hyperinflate_2008.pdf) (personal communication Dr Hishikawa) . Contrary to Dr Roehr's claims, such a hybrid device using an expiratory flow resister to develop PEEP/mask CPAP and a flow bag squeezed to provide the required PIP is not a SIB. The findings of increased pulmonary air leak associated with its use in providing mask CPAP are a timely warning of 'treatment creep' and the use of t-piece devices to deliver PEEP in term resuscitation.

    In conclusion, the statement by Laerdal in their product insert regarding the variable leak from the Laerdal clip-on expiratory diverter raises questions concerning the reliability of papers cited in the 2015 ILCOR Guidelines using Laerdal SIB with PEEP valves2-4. The use of the approximate PEEP valve markings to set the delivered PEEP without calibration may produce unreliable findings in studies aimed at estimating PEEP valve performance9;10.

    Reference List

    (1) Tracy M, Shah D, Priyadarshi A et al. The effectiveness of Ambu neonatal self-inflating bag to provide consistent positive end-expiratory pressure. Arch Dis Child Fetal Neonatal Ed 2016.

    (2) Morley CJ, Dawson JA, Stewart MJ et al. The effect of a PEEP valve on a Laerdal neonatal self-inflating resuscitation bag. J Paediatr Child Health 2010; 46(1-2):51-56.

    (3) Kelm M, Proquitte H, Schmalisch G et al. Reliability of two common PEEP-generating devices used in neonatal resuscitation. Klin Padiatr 2009; 221(7):415-418.

    (4) Dawson JA, Gerber A, Kamlin CO et al. Providing PEEP during neonatal resuscitation: which device is best? J Paediatr Child Health 2011; 47(10):698-703.

    (5) Hartung JC, Wilitzki S, Thio-Lluch M et al. Reliability of Single -Use PEEP-Valves Attached to Self-Inflating Bags during Manual Ventilation of Neonates - An In Vitro Study. PLoS One 2016; 11(2):e0150224.

    (6) Hartung JC, Schmolzer G, Schmalisch G et al. Repeated thermo- sterilisation further affects the reliability of positive end-expiratory pressure valves. J Paediatr Child Health 2013; 49(9):741-745.

    (7) Hartung JC, te Pas AB, Fischer H et al. Leak during manual neonatal ventilation and its effect on the delivered pressures and volumes: an in vitro study. Neonatology 2012; 102(3):190-195.

    (8) Hishikawa K, Goishi K, Fujiwara T et al. Pulmonary air leak associated with CPAP at term birth resuscitation. Arch Dis Child Fetal Neonatal Ed 2015; 100(5):F382-F387.

    (9) Roehr CC, Kelm M, Fischer HS et al. Manual ventilation devices in neonatal resuscitation: tidal volume and positive pressure-provision. Resuscitation 2010; 81(2):202-205.

    10) Hartung JC, Schmolzer G, Schmalisch G et al. Repeated thermo- sterilisation further affects the reliability of positive end-expiratory pressure valves. J Paediatr Child Health 2013; 49(9):741-745.

    Conflict of Interest:

    None declared

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  9. The reliability and safety of self-inflating bags for PIP/ PEEP delivery to neonates is all but clear

    Dear Sirs, We read with interest the recent work by Dr Tracy and colleagues: "The effectiveness of Ambu neonatal self-inflating bag to provide consistent positive end-expiratory pressure", doi:10.1136/ archdischild-2015-308649 ADC FN&N Ed. 2016.

    We would like to comment on the statement and findings by Tracy et al. Firstly, a strong point of the paper is that the authors have systematically investigated the reliability of single and multiple use SIBs and valves. Also, the observation that PEEP provision varies within differently compliant systems is particularly noteworthy, especially when using SIBs on newborn infants who are known to portray rapidly changing lung mechanics. For instance, the well-known work by Bjoerklund et al. and Dreyfuss et al. highlighted the importance of tight PIP control when ventilating newborn lungs (Bjoerklund 1996; Dreyfuss 1997). We further read with interest that Tracy et al. found the strongest correlation between inflations per minute (IPM) and accuracy of PEEP provision when IPM was 60min-1. Authors thereby replicated previous results by Morley et al. and Kelm et al. and others (Morley 2010, Kelm 2009).

    Conversely, we are surprised to read that Tracy and co-authors suggest that a) the Ambu SIB/PEEP-valve combination, used together with the Ambu manometer, has not been previously studied. This is not correct; several investigators have researched the reliability of manual ventilation devices, incl. SIB/ PEEP-valve combinations. And b) we believe that the author's concluding strong statement on the safety of the Ambu SIB/PEEP-valve combination needs to be revisited in the light of findings by other authors, as outlined below.

    The Ambu SIB/PEEP-valve combination, with or without the attachable manometer, has been studied in detail by several groups of investigators (Hartung et al. 2012, 2013, 2014 & 2016; Thio et al. 2010 & 2014; Kelm et al. 2012). As an example, Hartung and colleagues recently investigated the reliability of the delivered end-expiratory pressures from the Ambu SIB, together with Ambu 10-PEEP-valves, both with single use and multiple use PEEP-valves (Hartung 2013 & Hartung 2014 & Hartung 2016). However, much different to Tracy and colleagues' findings, these studies showed significant variation in their PEEP provision, even when factory new Ambu-10-PEEP-valves were tested on a new Ambu Mark IV SIB (Ambu Ballerup, Denmark) under highly standardized conditions: PEEPs ranged from 2.0 cmH2O to 5.15 cmH2O when set at 5 cmH2O, and 5.0 to 9.08 when set at 10cmH2O, respectively. Hartung et al. further found that repeated thermo sterilization continued to decrease the reliability of the tested Ambu multi-use PEEP-valves (Hartung 2013).

    It is common to most in vitro-studies on the provision of PIP/ PEEP that these, for obvious advantages such as repeatability of the tests etc., are conducted under controlled circumstances, including the use of leak free models. However, as shown by both Wood et al. and Schilleman et al., large mask leaks constantly occur during manual ventilation of babies, which impact significantly on the efficiency of manual ventilation (Wood 2008, Schilleman 2010). Accordingly, previous work by Hartung et al. investigated how leak affected the provision of PIP/ PEEP when using the SIB. The findings were that increased leak correlated with decreased PIP and PEEP provision when using a SIB/PEEP-valve combination, whereas the tested T-piece resuscitator (Neopuff, Fisher and Paykel Healthcare, Auckland, NZ), a continuous flow device, steadily compensated for leaks up to 85% (Hartung 2012). But, we believe that recommendations for real life, clinical scenarios, even when based on convincing laboratory data, need to be made with considerably caution, when the results stem from highly controlled laboratory studies.

    Lastly, Tracy et al. studied a lung model which was ventilated by a human operator, whereas the aforementioned studies by Hartung et al. were performed using a standardized plunger-driver to exclude variations in pressures as seen in manually delivered inflations (Hartung 2012 & 2013 & 2016). Therefore, we would like to strongly caution against Tracy et al.'s statement, which, based on their findings from only three investigators, confidently states that it would be possible to consistently deliver a required PIP by hand when using an Ambu SIB/PEEP- valve combination with manometer. The concept of the "educated hand" has long been refuted, for instance in studies by Bennett et al. (Bennett 2005), Hartung et al. (Hartung 2014), van Vonderen et al. (van Vonderen 2014) or Roehr and colleagues (Roehr 2012). They, as well as other authors, proved the highly significant variation in the delivery of positive pressure ventilation by human operators when using SIB/ PEEP- valve combinations. Reassuringly, and not dissimilar to Tracy's observations, Kelm et al. were able to show that specific training in target PIP delivery improved PIP provision in neonatal practitioners (Kelm 2010) and Hartung et al. showed that use of the Ambu pressure manometer helped with adherence to target PIPs, when compared to no manometer use (Hartung 2014). However, worryingly we read the very recent reports from Japan, in which an increased incidence of pneumothoraces in resuscitated term born infants (by use of SIB) has been lamented since the 2010 change in neonatal resuscitation guidelines, as featured in ADC F&N, together with an accompanying editorial by Ruediger and Poets (Hishikawa 2015; Ruediger 2015).

    To conclude, our current understanding of the limited body of literature on SIB use in neonates suggests that the safest means to provide safe and effective manual ventilation for preterm infants requiring resuscitation still remains to be established. Given the discrepancy between the available in-vitro and in-vivo studies, and in keeping with Tracy's final conclusion, we strongly caution that before sound conclusions about the reliability and safety of any SIB device are made, further research is needed. More efforts need to be made to establish in order to determine the safest and most effective way of in delivering manual ventilation to babies during neonatal resuscitation.

    Charles C Roehr, Gerd Schmalisch, Julia C Hartung March 2nd 2016

    References: Tracy M, Shah D, Priyadarshi A, Hinder M. The effectiveness of Ambu neonatal self-inflating bag to provide consistent positive end-expiratory pressure. Arch Dis Child Fetal Neonatal Ed. 2016 Jan 19. pii: fetalneonatal-2015-308649. doi: 10.1136/archdischild-2015-308649. [Epub ahead of print]

    Bjoerklund LJ, Vilstrup CT, Larsson A, Svenningsen NW, Werner O. Changes in lung volume and static expiratory pressure-volume diagram after surfactant rescue treatment of neonates with established respiratory distress syndrome. Am J Respir Crit Care Med. 1996; 154: 918-23.

    Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med. 1998; 157: 294-323.

    Morley CJ, Dawson JA, Stewart MJ, Hussain F, Davis PG. The effect of a PEEP valve on a Laerdal neonatal self-inflating resuscitation bag. J Paediatr Child Health. 2010; 46: 51-6.

    Kelm M, Proquitte H, Schmalisch G, Roehr CC. Reliability of two common PEEP-generating devices used in neonatal resuscitation. Klin Padiatr. 2009; 221: 415-8.

    Wood FE, Morley CJ, Dawson JA, Davis PG. A respiratory function monitor improves mask ventilation. Arch Dis Child Fetal Neonatal Ed. 2008; 93: F380-1.

    Schilleman K, Witlox RS, Lopriore E, Morley CJ, Walther FJ, te Pas AB. Leak and obstruction with mask ventilation during simulated neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed. 2010; 95: F398-402.

    Hartung JC, te Pas AB, Fischer H, Schmalisch G, Roehr CC. Leak during manual neonatal ventilation and its effect on the delivered pressures and volumes: an in vitro study. Neonatology. 2012; 102: 190-5.

    Hartung JC, Schm?lzer G, Schmalisch G, Roehr CC. Repeated thermo- sterilisation further affects the reliability of positive end-expiratory pressure valves. J Paediatr Child Health. 2013; 49: 741-5.

    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: 505-12.

    Hartung JC, Wilitzki S, Thio-Lluch M, Te Pas AB, Schmalisch G, Roehr CC. Reliability of Single-Use PEEP-Valves Attached to Self-Inflating Bags during Manual Ventilation of Neonates - An In Vitro Study. PLoS One. 2016;11(2):e0150224.

    Bennett S, Finer NN, Rich W, Vaucher Y. A comparison of three neonatal resuscitation devices. Resuscitation. 2005; 67: 113-8.

    van Vonderen JJ, Kamar R, Schilleman K, Walther FJ, Hooper SB, Te Pas AB. Influence of the hand squeeze and mask distensibility on tidal volume measurements during neonatal mask ventilation. Neonatology. 2013; 104: 216 -21.

    Roehr CC, Kelm M, Fischer HS, B?hrer C, Schmalisch G, Proquitt? H. Manual ventilation devices in neonatal resuscitation: tidal volume and positive pressure-provision. Resuscitation. 2010; 81: 202-5.

    Thio M, Dawson JA, Moss TJ, Galinsky R, Rafferty A, Hooper SB, Davis PG. Self-inflating bags versus T-piece resuscitator to deliver sustained inflations in a preterm lamb model. Arch Dis Child Fetal Neonatal Ed. 2014; 99: F274-7.

    Thio M, Bhatia R, Dawson JA, Davis PG. Oxygen delivery using neonatal self-inflating resuscitation bags without a reservoir. Arch Dis Child Fetal Neonatal Ed. 2010; 95: F315-9.

    Kelm M, Dold SK, Hartung J, Breckwoldt J, Schmalisch G, Roehr CC. Manual neonatal ventilation training: a respiratory function monitor helps to reduce peak inspiratory pressures and tidal volumes during resuscitation. J Perinat Med. 2012; 40: 583-6.

    Hishikawa K, Goishi K, Fujiwara T, Kaneshige M, Ito Y, Sago H. Pulmonary air leak associated with CPAP at term birth resuscitation. Arch Dis Child Fetal Neonatal Ed. 2015; 100: F382-7.

    Poets CF, Ruediger M. Mask CPAP during neonatal transition: too much of a good thing for some term infants? Arch Dis Child Fetal Neonatal Ed. 2015; 100: F378-9.

    Conflict of Interest:

    None declared

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  10. Calling a spade a digging implement

    May I suggest an alternative term for the egregious "upper extremity" used in the title of Labore and Befell's article. I believe that the body part to which they are referring is also known as an "arm"?

    Conflict of Interest:

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