Finn et al (1) describe respiratory adaptation in term infants following elective caesarean section and the other intervention of early cord clamping(2). Although the timing of cord clamping was not documented and there is no policy for delayed cord clamping at Cork University Maternity Hospital, the authors state that the neonates were transferred immediately after birth to a Panda Resuscitator and other non-invasive monitoring equipment, thus requiring early cord clamping in all infants studied.
The aim of the study was to define newborn physiological ventilation parameters (respiratory rate (RR), TV, end-tidal carbon dioxide (EtCO2)) over the first minutes of life in healthy-term infants following ECS, in the same way that Dawson and colleagues(3) produced centile charts in 2010 detailing the normalisation of oxygen saturations over time during newborn adaptation after normal vaginal birth. All the babies studied by Dawson et al also experienced a transition of the circulatory system which was interrupted by early cord clamping but, in a study in 2014 by Smit et al(4), in which cord clamping was delayed by at least one minute, they showed that cord clamping had resulted in a lower oxygen saturation during the first few minutes after birth. The median SpO2 of the babies experiencing early cord clamping was 11, 7 and 4% lower at minute 1, 2 and 3 respectively. All these babies already had the advantage of a physiological preparation through the mechanical and hor...
Finn et al (1) describe respiratory adaptation in term infants following elective caesarean section and the other intervention of early cord clamping(2). Although the timing of cord clamping was not documented and there is no policy for delayed cord clamping at Cork University Maternity Hospital, the authors state that the neonates were transferred immediately after birth to a Panda Resuscitator and other non-invasive monitoring equipment, thus requiring early cord clamping in all infants studied.
The aim of the study was to define newborn physiological ventilation parameters (respiratory rate (RR), TV, end-tidal carbon dioxide (EtCO2)) over the first minutes of life in healthy-term infants following ECS, in the same way that Dawson and colleagues(3) produced centile charts in 2010 detailing the normalisation of oxygen saturations over time during newborn adaptation after normal vaginal birth. All the babies studied by Dawson et al also experienced a transition of the circulatory system which was interrupted by early cord clamping but, in a study in 2014 by Smit et al(4), in which cord clamping was delayed by at least one minute, they showed that cord clamping had resulted in a lower oxygen saturation during the first few minutes after birth. The median SpO2 of the babies experiencing early cord clamping was 11, 7 and 4% lower at minute 1, 2 and 3 respectively. All these babies already had the advantage of a physiological preparation through the mechanical and hormonal adjustments that occur during labour and vaginal delivery, so it is quite possible early cord clamping may have an even greater effect on the circulation and respiratory function after elective CS. Animal studies suggest that the effect of early cord clamping is less if respiration and the pulmonary circulation is established. No doubt many of these babies will have already taken their first breath before the cord was clamped, but we do not know how big an effect early clamping had on the overall results. Thus this study only contributes to our understanding of respiratory adaption of the term neonate following elective caesarean section and early cord clamping. ILCOR and NICE both recommend delayed cord clamping at the birth of all uncompromised term neonates. All babies born by elective CS should have delayed clamping if these guidelines are being followed and it is our understanding of the respiratory adaption of these babies which is still needed.
References
1. Finn D, De Meulemeester J, Dann L, et al Respiratory adaptation in term infants following elective caesarean section Archives of Disease in Childhood - Fetal and Neonatal Edition 2018;103:F417-F421.
To the editor;
We have read the study of Hunt et al. describing the prediction of bronchopulmonary dysplasia (BPD) development at 1 week of age. (1). As it is very well known, BPD is a multifactorial disease with different clinical forms such as mild, moderate and severe. Early prediction of the disease is a clinically significant issue, such that early preventive measures may be taken, especially in cases with high risk. In our opinion, basing the prediction of BPD only on the ventilation requirement at 1 week of age is not appropriate. Respiratory distress syndrome and mechanical ventilation are important factors in the development of BPD but mechanical ventilation need is not sufficent enough for prediction in a disease with many risk factors. We had developed a simple clinical scoring system for the prediction of BPD, which takes into account the birthweight, gestational age, gender, hemodynamically signifiicant patent ductus arteriosus (HsPDA), respiratory distress syndrome, hypotension and intraventricular hemorrhage, at 72 hours of postnatal age (2). A score of less than 4 was considered as low, 4-6 as low intermediate, 7-9 as high intermediate and a score of above 9 was considered as high risk, in order to optimize the predictive values of lowest and highest categories. Among these parameters, HsPDA was the most significant one. The receiver operator curves (ROC) was 0.930, the negative predictive value of a score less than 4 were 95,9 whereas a positive pre...
To the editor;
We have read the study of Hunt et al. describing the prediction of bronchopulmonary dysplasia (BPD) development at 1 week of age. (1). As it is very well known, BPD is a multifactorial disease with different clinical forms such as mild, moderate and severe. Early prediction of the disease is a clinically significant issue, such that early preventive measures may be taken, especially in cases with high risk. In our opinion, basing the prediction of BPD only on the ventilation requirement at 1 week of age is not appropriate. Respiratory distress syndrome and mechanical ventilation are important factors in the development of BPD but mechanical ventilation need is not sufficent enough for prediction in a disease with many risk factors. We had developed a simple clinical scoring system for the prediction of BPD, which takes into account the birthweight, gestational age, gender, hemodynamically signifiicant patent ductus arteriosus (HsPDA), respiratory distress syndrome, hypotension and intraventricular hemorrhage, at 72 hours of postnatal age (2). A score of less than 4 was considered as low, 4-6 as low intermediate, 7-9 as high intermediate and a score of above 9 was considered as high risk, in order to optimize the predictive values of lowest and highest categories. Among these parameters, HsPDA was the most significant one. The receiver operator curves (ROC) was 0.930, the negative predictive value of a score less than 4 were 95,9 whereas a positive predictive values of a score more than 9 was 100. The validation of the results have yielded similar data. Other scoring systems may be found in the literature. Therefore we believe that the findings of Hunt et al should be interpreted with caution and more studies should be performed on the subject.
1) Hunt KA, Dassios T, Ali K, et al. Arch Dis Child Fetal neonatal Ed. Epub ahead of print, 2018; 18 October, doi: 10.1136/archdischild-2018-315343
2) Gürsoy T, Hayran M, Derin H, Ovali, F. A clinical scoring system to predict the development of bronchopulmonary dysplasia. Am J Perinatol 2015; 32(7): 659-66
Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.
Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.
Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).
References
1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001
2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276
Moral distress is a good 'umbrella' term but it tends to invite diversionary philosophising when in truth we all know that work in intensive care puts enormous emotional pressures on staff. These can be attended to but as the paper shows, cannot be eradicated. Health care is not a mechanical process. As one of the subjects in this study said "if we removed moral distress we would be like robots" (F443).
In my response to an earlier paper on this theme by the same authors https://adc.bmj.com/content/101/8/701.responses I discussed the benefits and limitations of facilitated discussions. One of the most striking comments from a neonatal intensive care nurse in one such meeting was "if you don't talk about it you don't know it's bad" http://bit.ly/1OyKcfl which perfectly captures our essential ambivalence about looking at troubling experiences in any depth. We are after all practitioners, and the tradition of 'getting on with it' - with occasional intelligent and practical thoughts on process - is the prevailing culture in most health services. Yet after almost 40 years as a psychiatrist in paediatric settings I know that there is a hunger for less systematic, but no less disciplined, attention to the daily experience of health work. This short paper 'stop running and start thinking' (Kraemer 2019...
Moral distress is a good 'umbrella' term but it tends to invite diversionary philosophising when in truth we all know that work in intensive care puts enormous emotional pressures on staff. These can be attended to but as the paper shows, cannot be eradicated. Health care is not a mechanical process. As one of the subjects in this study said "if we removed moral distress we would be like robots" (F443).
In my response to an earlier paper on this theme by the same authors https://adc.bmj.com/content/101/8/701.responses I discussed the benefits and limitations of facilitated discussions. One of the most striking comments from a neonatal intensive care nurse in one such meeting was "if you don't talk about it you don't know it's bad" http://bit.ly/1OyKcfl which perfectly captures our essential ambivalence about looking at troubling experiences in any depth. We are after all practitioners, and the tradition of 'getting on with it' - with occasional intelligent and practical thoughts on process - is the prevailing culture in most health services. Yet after almost 40 years as a psychiatrist in paediatric settings I know that there is a hunger for less systematic, but no less disciplined, attention to the daily experience of health work. This short paper 'stop running and start thinking' (Kraemer 2019 https://onlinelibrary.wiley.com/doi/abs/10.1111/camh.12282 ) summarises a parallel but subjugated tradition of respecting the curiosity and courage of front line workers which I hope can gain greater prominence in future.
To the editor:
We appreciate the work by Klotz et al., published in this journal1, who presented a randomized controlled cross-over trial to determine whether noninvasive high-frequency oscillatory ventilation (nHFOV) decreases CO2 partial pressure(pCO2) in premature infants more effectively than non-invasive continuous positive airway pressure(nCPAP). In this trial, they assigned 26 premature infants of less than 28 weeks’gestational age (GA) to receive either nHFOV or nasal continuous positive airway pressure (nCPAP) immediately after extubation or non-invasive
surfactant treatment. The authors could not etablish an increased
carbon dioxide clearance applying nHFOV compared with
nCPAP in this cohort of preterm infants. The result is in contrast
to previous reports where nHFOV was applied at higher airway
levels compared with nCPAP. Although the author provided brief information about the trial in the paper, we have the following questions about the details of the trial.
1. How was the mean airway pressure (MAP) titrated in the two sequences?
According to the paper, the range of MAPs applied in the two sequences were (5-8cmH2O)and (5-7cmH2O)respectively. The authors emphasized that the MAPs applied to nHFOV and nCPAP are equal, but it is not clear how was the MAP titrated (within the range) in the two sequences. Similar to what is done in invasive high frequency oscillatory ventilation, The MAP applied in nHFOV should be tit...
To the editor:
We appreciate the work by Klotz et al., published in this journal1, who presented a randomized controlled cross-over trial to determine whether noninvasive high-frequency oscillatory ventilation (nHFOV) decreases CO2 partial pressure(pCO2) in premature infants more effectively than non-invasive continuous positive airway pressure(nCPAP). In this trial, they assigned 26 premature infants of less than 28 weeks’gestational age (GA) to receive either nHFOV or nasal continuous positive airway pressure (nCPAP) immediately after extubation or non-invasive
surfactant treatment. The authors could not etablish an increased
carbon dioxide clearance applying nHFOV compared with
nCPAP in this cohort of preterm infants. The result is in contrast
to previous reports where nHFOV was applied at higher airway
levels compared with nCPAP. Although the author provided brief information about the trial in the paper, we have the following questions about the details of the trial.
1. How was the mean airway pressure (MAP) titrated in the two sequences?
According to the paper, the range of MAPs applied in the two sequences were (5-8cmH2O)and (5-7cmH2O)respectively. The authors emphasized that the MAPs applied to nHFOV and nCPAP are equal, but it is not clear how was the MAP titrated (within the range) in the two sequences. Similar to what is done in invasive high frequency oscillatory ventilation, The MAP applied in nHFOV should be titrated according to open lung strategy, performing alveolar recruitment, as published elsewhere2. Open lung strategy is the key to the application of nHFOV, however, it is rarely applied in nCPAP. The most commonly pressure range of CPAP is 3-10cmH2O. In fact, the MAP of higher than 10 cmH2O was often applied in some premature infants with severe respiratory distress syndrome(RDS) or the high risk of developing bronchopulmonary dysplasia(BPD) to perform alveolar recruitment. If MAP used in the nHFOV sequence was not based on open lung strategy but according to nCPAP setting, then the effect of nHFOV and the impact of the oscillations may be greatly dampened due to alveolar collapse. Therefore, providing more details about the adjustments of MAP over time both in the nHFOV and the nCPAP sequence would be extremely helpful to the reader and for future study protocols.
2. How long is the washout period in their trial?
According to the paper, the authors did not describe the length of the washout period. In the design of cross-over trial, the length of washout period should be considered. A recent randomized crossover trial by Ruegger et al.3, the washout period is thirty minutes. If there is no washout period preceded on the assigned therapy in their trial, the statistical results may be affected.
While answers to the above-mentioned questions will enhance our understanding of the promising data presented by Klotz et al. Given the increasing interest in avoiding invasive mechanical ventilation in very preterm infants, it may be time to embark on the first multicenter randomized controlled trial that investigates the effects of nHFOV in very preterm infants.
We appreciate the comments of Zhu and Shi on our crossover trial comparing nHFOV (nasal high frequency oscillatory ventilation) and nCPAP (nasal continuous positive airway pressure) in preterm infants <32 weeks gestational age after extubation from invasive ventilation for respiratory distress syndrome or after less invasive surfactant therapy.1
The aim of our study was to evaluate the efficacy of an oscillatory pressure waveform superposed to CPAP in spontaneously breathing preterm infants suffering from hypercarbia. In our trial, patients received a CPAP of 5 – 8 cmH2O, which represents standard of care in our unit and is in line with the clinical practice within many neonatal centers.2 Individual CPAP levels were the same before (adjusted according to standard of care) and within the study periods.
We agree with Zhu et al that increasing the CPAP level in addition to oscillations may enhance lung recruitment and ventilation. However, the effect of oscillations can hardly be differentiated from elevated CPAP levels in this scenario. Other factors than increased lung recruitment might contribute to increased CO2 clearance (e.g. increased leak flow, increased pharyngeal washout or the infants’ respiratory response). In conclusion, we cannot speculate on the effect of increased CPAP levels when testing nHFOV in our trial, but we would advise against testing differing opening pressures when comparing nHFOV to CPAP respiratory support.
We appreciate the comments of Zhu and Shi on our crossover trial comparing nHFOV (nasal high frequency oscillatory ventilation) and nCPAP (nasal continuous positive airway pressure) in preterm infants <32 weeks gestational age after extubation from invasive ventilation for respiratory distress syndrome or after less invasive surfactant therapy.1
The aim of our study was to evaluate the efficacy of an oscillatory pressure waveform superposed to CPAP in spontaneously breathing preterm infants suffering from hypercarbia. In our trial, patients received a CPAP of 5 – 8 cmH2O, which represents standard of care in our unit and is in line with the clinical practice within many neonatal centers.2 Individual CPAP levels were the same before (adjusted according to standard of care) and within the study periods.
We agree with Zhu et al that increasing the CPAP level in addition to oscillations may enhance lung recruitment and ventilation. However, the effect of oscillations can hardly be differentiated from elevated CPAP levels in this scenario. Other factors than increased lung recruitment might contribute to increased CO2 clearance (e.g. increased leak flow, increased pharyngeal washout or the infants’ respiratory response). In conclusion, we cannot speculate on the effect of increased CPAP levels when testing nHFOV in our trial, but we would advise against testing differing opening pressures when comparing nHFOV to CPAP respiratory support.
We furthermore agree with Zhu et al. that careful consideration has to be given to the individual significance of an intervention free interval in between study periods when planning a cross-over trial.3 However, there is an incongruence across cross-over trials on the use of washout phases and the issue of carry-over effects.4 As detailed in the manuscript, there was no washout phase between both study periods since a wash out in the classical meaning (omission of respiratory support) was not feasible in our trial. Even so, we calculated the carry-over effect for any outcome parameter and found none (table 2).1
We thank Zhu et al for their comments and hope our reply clarified those important aspects to the reader.
References:
1 Klotz D, Schneider H, Schumann S, et al. Non-invasive high-frequency oscillatory ventilation in preterm infants: a randomised controlled cross-over trial. Arch Dis Child Fetal Neonatal Ed 2018;103:F1–F5 . doi: 10.1136/archdischild-2017-313190
2 Beltempo M, Isayama T, Vento M, et al. Respiratory Management of Extremely Preterm Infants: An International Survey. Neonatology 2018;114:28–36 . doi: 10.1159/000487987
3 Wellek S, Blettner M. On the proper use of the crossover design in clinical trials: part 18 of a series on evaluation of scientific publications. Dtsch Arztebl Int 2012; 109:276–281. doi: 10.3238/arztebl.2012.0276
4 Mills EJ, Chan A-W, Wu P, et al. Design, analysis, and presentation of crossover trials. Trials 2009;10:27. doi: 10.1186/1745-6215-10-27
This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .
The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.
It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.
The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).
This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .
The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.
It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.
The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).
I suggest a target of 90-95% pre-ductal oxygen saturation for resuscitation of the extremely low birth weight newborn from the first acquisition of a saturation signal and through to NICU admission and beyond. Targeting 90 – 95% accords with recommended management of oxygen saturations in the NICU(4) and thus has the added benefit of being familiar to clinical staff. In practice such a simplified target still leaves clinicians with decisions around titration of inspired oxygen and in particular the optimal size of each incremental step in oxygen percentage.
Optimising the titration of oxygen once a saturation target has been decided upon probably requires consideration of individual patient factors such as airway patency, ventilation adequacy, and co-morbidities.
Individual patient analysis of the study data already available may allow the individualized prediction of optimal startingFiO2 to more reliably reach the saturation target in the first few minutes.
1. Oei JL, Finer NN, Saugstad OD, et al. Outcomes of oxygen saturation targeting during delivery room stabilisation of preterm infants. Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 07 October 2017. doi:10.1136/archdischild-2016-312366
2. Gluck PA. Medical Error Theory. Obstet Gynecol Clin North Am. 2008 Mar;35(1):11-17.
3. Bornhorst B, Peter CS, Poets CF. Detection of hyperoxaemia in neonates: data from three new pulse oximeters. Arch Dis Child Fetal Neonatal Ed. 2002 Nov;87(3):F217-9
4. Martin A. Neonatal target oxygen levels for preterm infants. In UpToDate, Post, TW (Ed), UpToDate, Waltham,MA,2017.
We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...
We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dramatically over the last 10 years, from the use of static levels of pure oxygen without SpO2 monitoring to blending oxygen to meet SpO2 values derived from full-term, healthy infants (3). Much more information is required before we can be confident that any SpO2 or FiO2 recommendations are in the best interest of the infant, especially one that is as physiologically complex as the extremely preterm infant.
In conclusion, we agree with Dr Hewson that the practice of SpO2 targeting and FiO2 titration for preterm infant resuscitation deserves further (and urgent) study. Until such data are available, we advise caution when using oxygen during preterm infant resuscitation and that clinicians should remember to tailor their resuscitation practice to meet the needs of each infant.
1. Wilson A, Vento M, Shah PS et al. A review of international clinical practice guidelines for the use of oxygen in the delivery room resuscitation of preterm infants. Acta Paediatr. 2018;107(1):20-27.
2. Dawson JA, Kamlin CO, Vento M et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics. 2010;125(6):e1340-7.
3. No authors listed. Co-publishing of the Pediatric and Neonatal Portions of the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2015;136 Suppl 2:S83-7.
It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...
It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left with gnawing, nebulous distress without adequate ways to root out and rectify its causes" (p. 324). So before moral distress is declared as beneficial and inevitable, a clear definition of the concept must be set forth and adhered to.
Dudzinski, D. M. (2016). Navigating moral distress using the moral distress map. Journal of Medical Ethics, 42(5), 321-324. doi:10.1136/medethics-2015-103156
Epstein, E. G. & Hurst, A. R. (2017). Looking at the Positive Side of Moral Distress: Why It's a Problem. Journal of Clinical Ethics, 28(1), 37-41.
Rambur, B., Vallett, C., Cohen, J. A., & Tarule, J. (2010). The moral cascade: Distress, eustress, and the virtuous organization. Journal of Organizational Moral Psychology, 1(1), 41-54.
Selye, H. (1974). Stress without distress. Philadelphia, PA: Lippincott, Williams, and Wilkins.
Wocial, L. D., & Weaver, M. T. (2013). Development and psychometric testing of a new tool for detecting moral distress: the Moral Distress Thermometer. Journal of Advanced Nursing, 69(1), 167-174. doi:10.1111/j.1365-2648.2012.06036.x
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and many of our research participants – also think moral distress may not always be avoidable nor negative.
Disproportionate or aggressive medical treatments considered not in a patient’s best interests are commonly cited as key causes of moral distress(Prentice, Janvier et al. 2016). This may occur when there is disagreement between the treating team and the family, due to differently held beliefs and values. Though principles of harm draw some guidance around the role of parents in decision-making, many of these cases still fall within the broad ‘zone of parental discretion’(Gillam 2016, McDougall, Gillam et al. 2016). If we accept that parents have a significant role in decision-making and are ethically permitted to choose options for their child that are not (in our opinion) ideal, then a degree of moral distress is ‘inevitable’. This inevitability stems from differences in subjective beliefs and values and does not necessarily reflect an organisational failing as Epstein suggests(Epstein and Hurst 2017). The experience of moral distress in these situations – in accordance with standard definitions– can be traumatic and we do not mean to downplay this in any way. Yet as Dudinski notes “[m]oral intuitions should not be ignored, nor are they definitive. They must bear the weight of ethical scrutiny”(Dudzinski 2016). If we do not accept that moral distress can lead to constructive discussions, patient advocacy and a mechanism for progressive thought then we are left with moral distress acting as a vehicle for blame(Dudzinski 2016), often inferring that the clinical lead either is failing to listen to the concerns of others or lacks the moral courage to change the current management plan(Prentice 2017). Both of these may be unfair assumptions amidst the complex end-of-life considerations and decision-making dynamics. More worrisome is that the net effect may be to place undue pressure on the family to acquiesce to a particular treatment plan to resolve the net moral distress of the treating team – what we have elsewhere referred to as ‘moral transference’(Prentice, Gillam et al. 2017). The moral distress experienced by families is too often neglected in such conversations.
Moral distress is a burden, but it can also be something from which we can grow and learn, and our patients can benefit from. Should we not therefore be willing to accept some of its positive attributes along with all the bad? Is it fair for our patients’ families to bear the burden if we cannot?
Dudzinski, D. M. (2016). "Navigating moral distress using the moral distress map." Journal of Medical Ethics 42(5): 321-324.
Epstein, E. and A. Hurst (2017). "Looking at the Positive Side of Moral Distress: Why It's a Problem." Journal of Clinical Ethics 28(1): 37-41.
Gillam, L. (2016). "The zone of parental discretion: An ethical tool for dealing with disagreement between parents and doctors about medical treatment for a child." Clinical Ethics 11(1): 1-8.
McDougall, R., L. Gillam and H. Gold (2016). The zone of parental discretion. When Doctors and Parents Disagree. R. McDougall, C. Delany and L. Gillam, The Federation Press: 17.
Prentice, T. (2017). Accepting the Good with the Bad when Living with Moral Distress. AAP Section on Bioethics, American Academy of Pediatrics.
Prentice, T., A. Janvier, L. Gillam and P. G. Davis (2016). "Moral distress within neonatal and paediatric intensive care units: a systematic review." Archives of Disease in Childhood 101(8): 701-708.
Prentice, T. M., L. Gillam, P. G. Davis and A. Janvier (2017). "The use and misuse of moral distress in neonatology." Seminars in Fetal and Neonatal Medicine.
Finn et al (1) describe respiratory adaptation in term infants following elective caesarean section and the other intervention of early cord clamping(2). Although the timing of cord clamping was not documented and there is no policy for delayed cord clamping at Cork University Maternity Hospital, the authors state that the neonates were transferred immediately after birth to a Panda Resuscitator and other non-invasive monitoring equipment, thus requiring early cord clamping in all infants studied.
The aim of the study was to define newborn physiological ventilation parameters (respiratory rate (RR), TV, end-tidal carbon dioxide (EtCO2)) over the first minutes of life in healthy-term infants following ECS, in the same way that Dawson and colleagues(3) produced centile charts in 2010 detailing the normalisation of oxygen saturations over time during newborn adaptation after normal vaginal birth. All the babies studied by Dawson et al also experienced a transition of the circulatory system which was interrupted by early cord clamping but, in a study in 2014 by Smit et al(4), in which cord clamping was delayed by at least one minute, they showed that cord clamping had resulted in a lower oxygen saturation during the first few minutes after birth. The median SpO2 of the babies experiencing early cord clamping was 11, 7 and 4% lower at minute 1, 2 and 3 respectively. All these babies already had the advantage of a physiological preparation through the mechanical and hor...
Show MoreTo the editor;
Show MoreWe have read the study of Hunt et al. describing the prediction of bronchopulmonary dysplasia (BPD) development at 1 week of age. (1). As it is very well known, BPD is a multifactorial disease with different clinical forms such as mild, moderate and severe. Early prediction of the disease is a clinically significant issue, such that early preventive measures may be taken, especially in cases with high risk. In our opinion, basing the prediction of BPD only on the ventilation requirement at 1 week of age is not appropriate. Respiratory distress syndrome and mechanical ventilation are important factors in the development of BPD but mechanical ventilation need is not sufficent enough for prediction in a disease with many risk factors. We had developed a simple clinical scoring system for the prediction of BPD, which takes into account the birthweight, gestational age, gender, hemodynamically signifiicant patent ductus arteriosus (HsPDA), respiratory distress syndrome, hypotension and intraventricular hemorrhage, at 72 hours of postnatal age (2). A score of less than 4 was considered as low, 4-6 as low intermediate, 7-9 as high intermediate and a score of above 9 was considered as high risk, in order to optimize the predictive values of lowest and highest categories. Among these parameters, HsPDA was the most significant one. The receiver operator curves (ROC) was 0.930, the negative predictive value of a score less than 4 were 95,9 whereas a positive pre...
Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.
Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.
Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).
References
1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001
2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276
Moral distress is a good 'umbrella' term but it tends to invite diversionary philosophising when in truth we all know that work in intensive care puts enormous emotional pressures on staff. These can be attended to but as the paper shows, cannot be eradicated. Health care is not a mechanical process. As one of the subjects in this study said "if we removed moral distress we would be like robots" (F443).
In my response to an earlier paper on this theme by the same authors https://adc.bmj.com/content/101/8/701.responses I discussed the benefits and limitations of facilitated discussions. One of the most striking comments from a neonatal intensive care nurse in one such meeting was "if you don't talk about it you don't know it's bad" http://bit.ly/1OyKcfl which perfectly captures our essential ambivalence about looking at troubling experiences in any depth. We are after all practitioners, and the tradition of 'getting on with it' - with occasional intelligent and practical thoughts on process - is the prevailing culture in most health services. Yet after almost 40 years as a psychiatrist in paediatric settings I know that there is a hunger for less systematic, but no less disciplined, attention to the daily experience of health work. This short paper 'stop running and start thinking' (Kraemer 2019...
Show MoreTo the editor:
Show MoreWe appreciate the work by Klotz et al., published in this journal1, who presented a randomized controlled cross-over trial to determine whether noninvasive high-frequency oscillatory ventilation (nHFOV) decreases CO2 partial pressure(pCO2) in premature infants more effectively than non-invasive continuous positive airway pressure(nCPAP). In this trial, they assigned 26 premature infants of less than 28 weeks’gestational age (GA) to receive either nHFOV or nasal continuous positive airway pressure (nCPAP) immediately after extubation or non-invasive
surfactant treatment. The authors could not etablish an increased
carbon dioxide clearance applying nHFOV compared with
nCPAP in this cohort of preterm infants. The result is in contrast
to previous reports where nHFOV was applied at higher airway
levels compared with nCPAP. Although the author provided brief information about the trial in the paper, we have the following questions about the details of the trial.
1. How was the mean airway pressure (MAP) titrated in the two sequences?
According to the paper, the range of MAPs applied in the two sequences were (5-8cmH2O)and (5-7cmH2O)respectively. The authors emphasized that the MAPs applied to nHFOV and nCPAP are equal, but it is not clear how was the MAP titrated (within the range) in the two sequences. Similar to what is done in invasive high frequency oscillatory ventilation, The MAP applied in nHFOV should be tit...
Dear Editor
We appreciate the comments of Zhu and Shi on our crossover trial comparing nHFOV (nasal high frequency oscillatory ventilation) and nCPAP (nasal continuous positive airway pressure) in preterm infants <32 weeks gestational age after extubation from invasive ventilation for respiratory distress syndrome or after less invasive surfactant therapy.1
The aim of our study was to evaluate the efficacy of an oscillatory pressure waveform superposed to CPAP in spontaneously breathing preterm infants suffering from hypercarbia. In our trial, patients received a CPAP of 5 – 8 cmH2O, which represents standard of care in our unit and is in line with the clinical practice within many neonatal centers.2 Individual CPAP levels were the same before (adjusted according to standard of care) and within the study periods.
...Show MoreWe agree with Zhu et al that increasing the CPAP level in addition to oscillations may enhance lung recruitment and ventilation. However, the effect of oscillations can hardly be differentiated from elevated CPAP levels in this scenario. Other factors than increased lung recruitment might contribute to increased CO2 clearance (e.g. increased leak flow, increased pharyngeal washout or the infants’ respiratory response). In conclusion, we cannot speculate on the effect of increased CPAP levels when testing nHFOV in our trial, but we would advise against testing differing opening pressures when comparing nHFOV to CPAP respiratory support.
This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .
The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.
It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.
The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).
I suggest a target of 90...
Show MoreWe thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...
Show MoreIt is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...
Show MoreWe agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...
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