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Supporting breathing of preterm infants at birth: a narrative review
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  • Published on: 13 December 2018
    End-expiratory pressure during the respiratory transition: a more complex tale?

    I agree with the authors that the question of end-expiratory pressure at birth needs to focus on CPAP. As the authors highlight, the entirety of the preclinical literature has been performed in mechanically ventilated, intubated and sedated animals, and the role of PEEP on pulmonary blood flow during the actual respiratory transition is yet to be investigated. Neither of these limitations are insurmountable and I am confident the authors can rectify this gap in knowledge.
    The rapidly changing cardiorespiratory events immediately following birth and the concerns regarding with too low and too high a PEEP further emphasise the need for a dynamic approach to PEEP levels.

    Conflict of Interest:
    None declared.
  • Published on: 13 December 2018
    Response to letter to the editor: ‘End-expiratory pressure during the respiratory transition: a more complex tale?’
    • Tessa Martherus, Dr Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands

    Tessa Martherus1, André Oberthuer2, Janneke Dekker1, Stuart B Hooper3,4, Erin V McGillick3,4, Angela Kribs2, Arjan B te Pas1

    1 Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
    2 Department of Neonatology, Children’s Hospital University of Cologne, Cologne, Germany
    3 The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
    4 Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia

    We thank the author for his interest in our review and for acknowledging that it is timely. In our review we cover the support of spontaneous breathing infants at birth with CPAP and discuss what CPAP pressures should be used. The clinical paper the author is referring to is beyond the scope of this review as the infants were 12-18 hours old and this is a completely different situation dealing with different pulmonary characteristics. In our opinion, mechanical ventilation and PEEP in intubated newborns has very little to contribute to this discussion other than indicating how end-expiratory pressures can improve lung aeration and that at high levels they have a negative impact on pulmonary blood flow and venous return. These points were adequately covered in the references cited and we also note that none of the author's papers report how high PEEP levels impact on pulmonary blood flow....

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    Conflict of Interest:
    None declared.
  • Published on: 13 December 2018
    End-expiratory pressure during the respiratory transition: a more complex tale?
    • David G Tingay, Neonatologist/NHMRC Career Development Fellow Murdoch Children's Research Institute

    Dear Editors,
    I read with interest the review article of Martherus and co-workers entitled ‘Supporting breathing of preterm infants at birth: a narrative review’. Despite the ongoing focus on the respiratory transition at birth, clinical strategies that improve outcome are lacking. As such the authors should be congratulated on this timely review. As they emphasise, there is still a dearth of human data, and much of the literature regarding pressure strategies at birth remains in the domain of preclinical studies. The authors thus appropriately focused on the preclinical literature with regards to CPAP and PEEP levels, acknowledging that end-expiratory pressure remains the foundation of respiratory support. Table 1 and the accompanying text unfortunately do not fully achieve the authors stated aims of providing a summary of ‘the currently available literature’ concerning the ‘effect of different CPAP strategies in the very preterm lung at birth.’ Whilst this section provides a nice summary of six worthy studies arising predominantly from the authors’ own lab it cannot be considered inclusive or complete.

    The authors suggest that PEEP titration maybe useful during the respiratory transition. In 2014 we were the first to report the use of a high PEEP titration strategy at birth in preterm lambs, providing an escalating and then de-escalating PEEP (dynamic) strategy with transient PEEP levels up to 20 cmH2O. We demonstrated improved oxygenation and lung mechanic...

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    Conflict of Interest:
    None declared.