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 cas...
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)
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 ; n...
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.
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 wa...
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.
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'
und...
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.
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
in...
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.
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
manu...
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.
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 t...
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.
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"?
To the editor:
As part of a review of the literature regarding the use of Povidone iodine
(PVI) to perform chemical pleurodesis in the management of congenital
chylothorax (CCT), we read with great interest the case reported by Resch
et al (1) and their following conclusion: "the risk-benefit assessment of
PVI pleurodesis in the treatment of congenital chylothorax does not
support its routine use as it may be associate...
To the editor:
As part of a review of the literature regarding the use of Povidone iodine
(PVI) to perform chemical pleurodesis in the management of congenital
chylothorax (CCT), we read with great interest the case reported by Resch
et al (1) and their following conclusion: "the risk-benefit assessment of
PVI pleurodesis in the treatment of congenital chylothorax does not
support its routine use as it may be associated with significant harm". We
believe that the current data are certainly insufficient to draw
definitive conclusions about the efficacy and safety of this procedure in
the neonate. Randomized studies on large neonatal population are required
to precise: the risks and benefits of this procedure, the timing and the
modalities of its realization (duration of intervention, dilution and
dosage of PVI) according to the patient's field (gestational age, weight
and associated morbidity).
However, we draw attention that significant harms after this procedure
were reported in only specific situations.
Brissaud O et al (2) reported the case of a newborn dead from end stage
renal failure, oliguria, hydrops, and refractory hypotension after PVI
pleurodesis. However, this patient had diffuse congenital lymphangectasia
in the autopsy. This condition would favorite iodine absorption and could
explain the worsening of oligoanuria and precipitation of renal failure in
this patient. In another case of CCT reported by Mitanchez et al (3),
lymphangiectasis was suspected and even chyle flow resolved within 24
hours, shock and acute renal failure occurred within 12 hours after
instillation. Severe chronic failure was persist 6 months later. Mitanchez
et al (3) have postulated that the pulmonary lymphangectasia would have
favored the massive iodine absorption and thus intoxication in both cases.
The case reported by Resch et al (1) combine tow risk factors for
developing severe side effects of PVI. First, he has a pulmonary
lymphangiectasia who already was jagged as a factor favoring systemic
absorption and thus intoxication by the product. Second, he received a
high concentration of PVI (10%) as the patient of Mitanchez et al (3).
This could also explain the amplification of the risk of major adverse.
Scottoni F et al (4) reported another hard situation of an extremely low
birth weight and premature infant with extensive deep central veins
thrombosis, abnormal renal function before treatment and who has developed
multiple organ failure after the procedure. In our opinion, all these
serious situations are likely to be either unresponsive to treatment or
predictive of major side effects and should be excluded.
References: 1 Resch B, Freidl T, Reiterer F. Povidone-iodine
pleurodesis for congenital chylothorax of the newborn. Arch Dis Child
Fetal Neonatal Ed Published Online First: 29 September 2015.
doi:10.1136/archdischild-2015- 309184
2-Brissaud O, Desfrere L, Mohsen R, Fayon M, Demarquez J. Congenital
idiopathic chylothorax in neonates: chemical pleurodesis with povidone-
iodine (Betadine). Arch Dis Child Fetal and Neonatal Ed. 2003;88(6):F531-
F533.
3-Mitanchez D, Walter-Nicolet E, Salomon R, Bavoux F, Hubert P. Congenital
chylothorax: what is the best strategy? Arch Dis Child. Fetal Neonatal Ed.
2006;91(2):F153.
4-Scottoni F, Fusaro F, Conforti A, et al. Pleurodesis with povidone-
iodine for refractory chylothorax in newborns: Personal experience and
literature review. J Pediatr Surg Published Online First: 28 April 2015.
doi:10.1016/j.jpedsurg.2015.03.069
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 cas...
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 ; n...
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 wa...
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
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' und...
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 in...
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 manu...
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 t...
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:
None declared
To the editor: As part of a review of the literature regarding the use of Povidone iodine (PVI) to perform chemical pleurodesis in the management of congenital chylothorax (CCT), we read with great interest the case reported by Resch et al (1) and their following conclusion: "the risk-benefit assessment of PVI pleurodesis in the treatment of congenital chylothorax does not support its routine use as it may be associate...
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