We would like respond to the eLetter from Dr Schmoelzer et al,
regarding
our paper entitled "Potential Hazard of the Neopuff T-Piece Resuscitator
in
the Absence of Flow Limitation".
Dr Schmoelzer et al have verified our findings that even an increase
in
flow from 5-15L/min will bring about a four-fold increase in PEEP, a
serious
potential hazard of the Neopuff. His failure to reproduce...
We would like respond to the eLetter from Dr Schmoelzer et al,
regarding
our paper entitled "Potential Hazard of the Neopuff T-Piece Resuscitator
in
the Absence of Flow Limitation".
Dr Schmoelzer et al have verified our findings that even an increase
in
flow from 5-15L/min will bring about a four-fold increase in PEEP, a
serious
potential hazard of the Neopuff. His failure to reproduce our maximum PIP
was due to his use of a lower flush flow meter.
We encourage all users of this device to investigate the effects of
changing
gas flow on their own systems, in order to be aware of the potential
hazards of the Neopuff device. We stand by the findings of our study that
there is a "Potential Hazard with the Neopuff T-Piece Resuscitator in the
absence of flow limitation".
Dear Editor:
The recent article of retrospective comparison of two methods, colour
Doppler ductal diameter and pulsed Doppler flow pattern, as
echocardiographic indicator for patent ductus arteriosus (PDA) treatment
in preterm infants by Condo' et al was well-designed and interesting.[1]
We agree the conclusions of that both methods are significantly
associated, and may use as a cross check to assist in the management o...
Dear Editor:
The recent article of retrospective comparison of two methods, colour
Doppler ductal diameter and pulsed Doppler flow pattern, as
echocardiographic indicator for patent ductus arteriosus (PDA) treatment
in preterm infants by Condo' et al was well-designed and interesting.[1]
We agree the conclusions of that both methods are significantly
associated, and may use as a cross check to assist in the management of
preterm infants with a PDA.
However, the following statement in the Discussion caused a little
concern: "If, instead, treatment is indicated by a pulsatile or growing
pattern, as was done in another RCT, a substantial proportion of infants
may be treated despite having a ductal diameter <2.0 mm". The reference
given here is our RCT.[2] Although, as found in their study, 40 of the 83
echocardiographic traces classified as growing or pulsatile had a diameter
<2.0 mm, their flow patterns did reveal a significant left to right
shunting and did reflect the realistically hemodynamic status of the PDA
that deserved treatment.
The authors described that 82.4% of the PH pattern group having ductal
diameter values >2.0 mm. However, there was no data showing the
percentage of transition from PH pattern to closing or closed pattern.
According to our previous reports,[3,4] about 50% of PH patterns remained
to be non-significant PDA and changed to closing or closed patterns. And
if a ductal diameter >2.0 mm is used as the indicator of treatment as
suggested by the authors, 41.2% infants with PDA of PH pattern may be
treated unnecessarily despite remaining non-significant and finally closed
spontaneously.
The authors indicated that a significant portion (28/197, 14.2%) of
echocardiographic studies had a flow pattern could not be clearly
classified. These traces appeared intermediate between the pulsatile and
closing patterns. We would like to remind that the classification of PDA
flow pattern depends on the profile of the pulsed Doppler wave form as
well as the flow velocity, the pulsatile pattern has a left to right
shunting with a pulsatile notched contour of peak flow velocity about 1.5
m/second, and closing pattern has a characteristic continuous profile with
a peak flow velocity of about 2 m/second.[3,4]
Finally, we would like to highlight the importance of the sequential
echocardiographic assessment of the hemodynamic status of PDA rather than
to depend only on a spot time measurement. What is most important is
whether the echocardiographically derived index can detect prospectively
the development of clinically significant PDA.
REFERENCES
1. Condo' M, Evans N, Bellu' R, Kluckow M. Echocardiographic assessment of
ductal significance: retrospective comparison of two methods. Arch Dis
Child Fetal Neonatal Ed on line first, published on May 5, 2011.
2. Su BH, Lin HC, Chiu HY, Hsieh HY, Chen HH, Tsai YC. Comparison of
ibuprofen and indometacin for early-targeted treatment of patent ductus
arteriosus in extremely premature infants: a randomised controlled trial.
Arch Dis Child Fetal Neonatal Ed 2008;93:F94-F99
3. Su BH, Watanabe T, Shimitzu M, et al. Echocardiographic assessment of
ductus
arteriosus shunt flow pattern in premature infants. Arch Dis Child Fetal
Neonatal Ed 1997;77: F36-40.
4. Su BH, Peng CT, Tsai Ch. Echocardiographic flow patterns of patent
ductus arteriosus: A guide to indomethacin treatment in premature infants.
Arch Dis Child Fetal Neonatal Ed 1999;81:F197-20.
It was with interest that I read the article by Whittaker et al
regarding toxic additives in medication for preterm infants, particularly
the assessment of alcohol intake in the infant population treated with
furosemide oral solution. I was surprised by the statement “ethanol
exposure in the preterm infants … ranged from 0.2mL to 1.8mL/ week
uncorrected for weight, the equivalent of a 70kg man consuming between 1
and 7...
It was with interest that I read the article by Whittaker et al
regarding toxic additives in medication for preterm infants, particularly
the assessment of alcohol intake in the infant population treated with
furosemide oral solution. I was surprised by the statement “ethanol
exposure in the preterm infants … ranged from 0.2mL to 1.8mL/ week
uncorrected for weight, the equivalent of a 70kg man consuming between 1
and 7 units”. I agree that the alcohol content of oral medications should
be of concern and that infants should not be exposed to alcohol if at all
possible. However I found the analogy with the weekly alcohol intake of
a 70kg man alarming and challenge this calculation.
Whittaker et al put forth two “safe limits”. The first is the
recommended safe weekly limit of ethanol consumption of 3mL/kg/week, the
other 0.14mL/kg/week. Which limit is to be used? The highest ethanol
exposure in neonates depicted in Figure 1 is approximately 0.6mL/kg/week.
Although this is equivalent to approximately 4 units of alcohol/week, it
does not exceed the stated safe weekly limit.
In Canada, furosemide 10mg/mL oral solution (Lasix) contains 0.2mL of
ethanol 95% in each milliliter (verbal communication with Sanofi-Aventis).
The usual dose used for chronic lung disease is 2mg/kg/day or
0.2mL/kg/day, equivalent to 1.4mL/kg/week. The amount of ethanol in this
volume of furosemide oral solution is 0.28mL/kg/week, equivalent to
approximately 2 units of alcohol/week, but not exceeding the stated safe
weekly limit.
The statements comparing alcohol intake in infants to that of a 70kg
male are not only alarming and sensationalized, but do not address the
balance of risk/benefit that must be considered when treating any medical
condition with a medication. Constructive alternatives should be sought to
avoid alcohol intake in infants.
We were pleased that our findings [2] and those of Tunell's group [3]
have been confirmed in the recent paper by van Vonderen et al [1], that is
the inspiratory efforts of prematurely born infants coinciding with
inflations during resuscitation at birth are critical in increasing the
expired carbon dioxide levels. In addition, we have previously published
the relationship between expired tidal volume and expired carbon dio...
We were pleased that our findings [2] and those of Tunell's group [3]
have been confirmed in the recent paper by van Vonderen et al [1], that is
the inspiratory efforts of prematurely born infants coinciding with
inflations during resuscitation at birth are critical in increasing the
expired carbon dioxide levels. In addition, we have previously published
the relationship between expired tidal volume and expired carbon dioxide
levels during resuscitation.[2] We were, however, confused by figure one
in the recent paper.[1] The trace documented as expired tidal volume, we
believe is not the expired tidal volume but rather the airway pressure.
Furthermore, in our experience of measuring expired carbon dioxide levels
at resuscitation in over 200 preterm infants using a similar technique, we
found, as one would expect, the carbon dioxide levels during the
inspiratory phase to fall to a stable baseline as documented in figure 1
of our published paper.[2] We were, therefore, surprised by the expired
carbon dioxide trace shown [1] and wonder how the expired carbon dioxide
was calculated from such a trace.
REFERENCES
1. van Vonderen JJ, Lista G, Cavigioli F, et al. Effectivity of
ventilation by measuring expired CO2 and RIP during stabilisation of
preterm infants at birth. Arch Dis Child Fetal Neonatal Ed 2015 [pub ahead
of print].
2. Murthy V, O;Rourke-Potocki A, Dattani N, et al. End tidal carbon
dioxide levels during the resuscitation of prematurely born infants.
Early Hum Dev 2012;88:783-7.
3. Palme-Kilander C, Tunell R. Pulmonary gas exchange during facemask
ventilation immediately after birth. Arch Dis Child 1993;68:11-6.
Dear Editor,
We read with great interest the article by Fumagalli et al.,1 who reported
subcutaneous fat necrosis (SFN) in an infant suffering perinatal hypoxic
injury and treated with total body cooling, which complicated by
hypercalcaemia. In their report,1 it is suggested that total body cooling
likely increase the risk of SFN and renal complications. Recently, we
report a case of SFN, which complicated by hypercalcaem...
Dear Editor,
We read with great interest the article by Fumagalli et al.,1 who reported
subcutaneous fat necrosis (SFN) in an infant suffering perinatal hypoxic
injury and treated with total body cooling, which complicated by
hypercalcaemia. In their report,1 it is suggested that total body cooling
likely increase the risk of SFN and renal complications. Recently, we
report a case of SFN, which complicated by hypercalcaemia, due to
perinatal hypoxic injury.2 Unlike case of Fumagalli et al.,1 our patient
did not undergo to hypothermia therapy. Hence, we would like to make some
comments on their report.
Firstly, it is reported that as if SFN is mainly caused by therapeutic
hypothermia in newborns. Although the hypothermia can cause to SFN,3 it
usually occurs secondary to some perinatal conditions about by postnatal
day five to seven.2 However, cold panniculitis appears 48 to 72 hours
after exposure to cold.4 Therefore, in case of Fumagalli et al.,1 SFN at
35 hour of life suggests the facilitating effect of cold stress.
Nevertheless, it should be emphasized that neonatal SFN is primarily
caused by perinatal asphyxia,1,2 but therapeutic hypothermia may
facilitate this process.
Secondly, marked nephrocalcinosis present in this case may suggest
prolonged severe hypercalcaemia. We wonder if the patient's kidneys
previously evaluated by ultrasound for any reason? As hypercalcaemia is an
expectant metabolic complication of SFN of newborn,1,2 these patients
should be closely monitored for development of hypercalcaemia, as reported
in present case. Nephrocalcinosis present in this case is due to
hypercalcaemia as a complication SFN, but not being hypothermia therapy.
However, although the hypothermia may cause renal damage,5 hypoxic-
ischemic injury itself is the main cause of renal injury in these cases.
Therefore, title of the article in which "Total body cooling: skin and
renal complications" is not consistent with the reported case.
In conclusion, SFN of the newborn is a disorder of the adipose tissue,
mostly affecting full-term or post-term infants who experience perinatal
distress. Nevertheless, though perinatal hypoxic-ischemic event is the
main cause of SFN, hypothermia may facilitate its development. In
addition, the patients with SFN should be closely monitored for developing
metabolic problems like hypercalcaemia.
REFERENCES
1. Fumagalli M, Ramenghi LA, Pisoni S, Borzani I, Mosca F. Total body
cooling: skin and renal complications. Arch Dis Child Fetal Neonatal Ed
2011;DOI: 10.1136/adc.2010.207886
2. Hakan N, Aydin M, Zenciroglu A, et al. Alendronate for the treatment of
hypercalcaemia due to neonatal subcutaneous fat necrosis. Eur J Pediatr
2011;DOI: 10.1007/s00431-011-1468-8
3. Markus JR, de Carvalho VO, Abagge KT, et al. Ice age: a case of cold
panniculitis. Arch Dis Child Fetal Neonatal Ed 2011;96:F200.
4. Torrelo A, Hern?ndez A. Panniculitis in children. Dermatol Clin
2008;26:491-500, vii.
5. Ura H, Asai Y, Mori K, Nara S, Yoshida M, Itoh Y. Total necrosis of the
pancreas and renal cortex secondary to hypothermia therapy. J Trauma
2002;52:987-9.
We read with interest the article by K Ganesan et al 1 about using
prophylactic oral Nystatin to prevent fungal colonisation and invasive
fungaemia. We strongly support this practice especially in preterm babies
who are on broad spectrum antibiotics.
It is interesting to know if the authors discovered any other
bacterial organisms apart from candida in there routine surveillance
swabs. We in our unit in Royal O...
We read with interest the article by K Ganesan et al 1 about using
prophylactic oral Nystatin to prevent fungal colonisation and invasive
fungaemia. We strongly support this practice especially in preterm babies
who are on broad spectrum antibiotics.
It is interesting to know if the authors discovered any other
bacterial organisms apart from candida in there routine surveillance
swabs. We in our unit in Royal Oldham hospital (large District Hospital 16
neonatal level 2 Cots) not only swab babies but also there
microenvironment, toys and religious items left in incubators and cots. In
a recent random safety study we found 16 items in 10 cots, surveillance
swabs taken form them revealed scanty growth of skin organisms in 7,
scanty to moderate growth of coliforms in 3 and scanty growth of
staphylococci in 1. It is interesting to note that none of these
environmental swabs demonstrated any fungal colonisation. In view of the
above study findings we follow a ‘No soft toys or religious items in
cots/incubators policy’ along with the enforcement of strict hand washing
policy.
Prophylactic nystatin could be the way forward to prevent fungal
colonisation but what about colonisation from other bacterial organisms?.
The age old saying ‘Prevention is better than cure’ stands true in our
fight against infection and hence the need to maintain a clean
microenvironment in the neonatal unit.
Phillips et.al (1) demonstrated the Neonatal Illness Prognosis
Indicator (NIPI) to be a good predictor of mortality in very low birth
weight neonates. We carried out a study replicating the design of the
original research to evaluate the use of this newly developed scoring
system in a different setting.
The study was based in Glan Clwyd District General Hospital,
Boddelwyddan, which has...
Phillips et.al (1) demonstrated the Neonatal Illness Prognosis
Indicator (NIPI) to be a good predictor of mortality in very low birth
weight neonates. We carried out a study replicating the design of the
original research to evaluate the use of this newly developed scoring
system in a different setting.
The study was based in Glan Clwyd District General Hospital,
Boddelwyddan, which has approximately 2500 deliveries a year and provides
Level 3 neonatal intensive care. Retrospective data on highest blood
lactate concentration, gestation and life threatening malformations was
collated to create an NIPI score for neonates weighing <1501 grams born
in the hospital between October 2008 and January 2011. The primary outcome
of death before discharge and secondary outcome of adverse event (using
the same criteria used in Phillips et.al's study) were used to assess the
NIPI's predictive ability. Local ethical and research approval was
granted for the study.
97 eligible babies were inborn during this time period of which 12
were excluded due to still being an inpatient at the time of the study or
transfer out to other hospitals. This left 85 babies which were included
in the study cohort. Predictive ability was determined from area under the
receiver operator curve (AUC). AUC for death before discharge was 0.932
(95 % confidence interval of 0.873 - 0.991) showing similar excellent
predictive value as the original validation cohort. AUC for adverse
outcome was calculated at 0.743 (95% confidence interval of 0.629 - 0.856)
and therefore did not show a clinically significant predictive ability.
This small study provides evidence that the NIPI score retains its
predictive ability for mortality when used in a different setting to that
which it was originally validated in. Larger studies in other varied
settings would be encouraged in order to fully assess its potential
clinical application.
1. Phillips, L. A., C. J. Dewhurst, Yoxall,C.W. The Prognostic Value
of Initial Blood Lactate Concentration Measurements in Very Low
Birthweight Infants and their use in Development of a new Disease Severity
Scoring System. Archives of disease in childhood. Fetal and neonatal
edition; 2011;96(4): F275-F280
We read with interest Laing’s article on controlling an outbreak of
MRSA in a neonatal unit. We have also learnt from outbreaks on our
neonatal unit. Laing et al talk about cohort nursing for those babies
found to be colonised. In our experience it is important to isolate/cohort
not just those babies that are MRSA colonised, but also to cohort those
babies whom are known contacts, with MRSA swabs repeated weekly. It is
i...
We read with interest Laing’s article on controlling an outbreak of
MRSA in a neonatal unit. We have also learnt from outbreaks on our
neonatal unit. Laing et al talk about cohort nursing for those babies
found to be colonised. In our experience it is important to isolate/cohort
not just those babies that are MRSA colonised, but also to cohort those
babies whom are known contacts, with MRSA swabs repeated weekly. It is
important that both staff and parents realise that a single negative MRSA
screen does not outrule low level colonisation in the baby. For this
reason, we continue to isolate or cohort nurse both MRSA positive babies
and their contacts until discharge from the neonatal unit. We ask that all
staff; including pharmacists and radiographers visit these rooms last when
visiting the neonatal unit. We ensure people maintain scrupulous hand
hygiene practices.
We acknowledge that the treatment of staff is contentious. Laing et
al mention anonymised staff screening. We have used a screen and treat
approach i.e, all staff are screened and immediately started on a
decolonisation protocol. The advantage of this approach is that positive
individuals do not usually have to be subsequently removed from duty.
Good communication is vital during such an outbreak. Regular meetings
briefing neonatal staff and also key individuals in affiliated departments
(e.g. obstetrics and midwifery), supported by circulated minutes ensure
that everyone is receiving the same information. We keep daily cot
position maps detailing where each baby is, so as to see how spread might
have occurred. If the neonatal unit closes, it is important to notify all
other hospitals within the perinatal network to ensure that they know that
they may be receiving a higher workload and will not be able to repatriate
babies back to the affected unit.
Dr Geraldine Ng, Consultant Neonatologist, St Mary’s Hospital,
Imperial College Healthcare NHS Trust, London
Dr Marianne Nolan, Consultant Microbiologist, St Mary’s Hospital,
Imperial College Healthcare NHS Trust, London
References
1. Laing IA, Gibb AP, McCallum A. Controlling an outbreak of MRSA in
the neonatal unit: a steep learning curve. Arch Dis Child 2009;94:F307-310
2. Deurenberg RH, Stobberingh EE. The molecular evolution of hospital
- and community-associated methicillin-resistant Staphylococcus aureus.
Curr Mol Med. 2009;9(2):100-15
Dear Sir,
First let me congratulate you for the phenomenal work that you have done
at Safdarjung Hospital.
On reading your paper, I found discrepancies in numbers in the flow
chart (Fig 1) and Table 2: viz. out of 1599 abnormal babies on pulse
oximetry, Echo confirmed 18 major and 15 critical CHDs. However, further
in the text and in table 2, the corresponding numbers are cited as 39
major and 22 critical CHDs...
Dear Sir,
First let me congratulate you for the phenomenal work that you have done
at Safdarjung Hospital.
On reading your paper, I found discrepancies in numbers in the flow
chart (Fig 1) and Table 2: viz. out of 1599 abnormal babies on pulse
oximetry, Echo confirmed 18 major and 15 critical CHDs. However, further
in the text and in table 2, the corresponding numbers are cited as 39
major and 22 critical CHDs. Consequently, the sensitivity, specificity and
other calculations are also confusing.
Sensitivity of pulse-oximetry for detecting any CHD according to your
study is 47.2%, whereas my calculations beg to differ, with the
sensitivity as 18.2% ie (29/159 x 100). This is of course, based on the
numbers given in the flow chart.
Kindly clarify the discrepancies in this otherwise well-written
paper.
To The Editor:
I read the article by Tracy et al with great interest (1). However I would
like to point out few issues that need explanation before the study
results can be accepted.
First, despite of more leak with one person method, the tidal volumes
being delivered are not statistically different in both the groups. Hence,
the superiority of this technique in decreasing the need of endotracheal
intubation and chest com...
To The Editor:
I read the article by Tracy et al with great interest (1). However I would
like to point out few issues that need explanation before the study
results can be accepted.
First, despite of more leak with one person method, the tidal volumes
being delivered are not statistically different in both the groups. Hence,
the superiority of this technique in decreasing the need of endotracheal
intubation and chest compression by improving ventilation is doubtful and
should be first tested in clinical studies before its widespread
implementation.
Second, surprisingly the tidal volumes generated in both the techniques
are much above the desired tidal volume of 4-5ml/kg. Animal studies have
clearly shown that ventilation even for 15 minutes at high tidal volumes
(15ml/kg) initiates' lung injury which in turn cause decreased lung
compliance and impaired gas exchange.
Third, the current Neonatal Resuscitation Programme guidelines recommend
the presence of one person at every delivery and two persons in high risk
deliveries (2). This new technique will require one extra resuscitator.
The burden of one more resuscitator will be a big challenge for developing
countries where 98% of total neonatal deaths occur worldwide (3).
Fourth, the sample size calculation has not been elaborated by the
authors.
Despite these limitations, I appreciate the authors for their work which
opens up new arenas of research in mask ventilation and neonatal
resuscitation.
References
1.Tracy MB, Klimek J, Coughtrey H, Shingde V, Ponnampalam G, M Hinder M et
al. Mask leak in one-person mask ventilation compared to two-person in
newborn infant manikin study. Arch Dis Child Fetal Neonatal Ed 2011;96:195
-200.
2.Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J
et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation 2010;122;909-919.
3.Carlo Wa, Goudar SS, Jehan I, Chomba E, Tshefu A, Garces A et al.
Newborn-Care Training and Perinatal Mortality in Developing Countries. N
Engl J Med 2010;362:614-23.
Dear Editor,
We would like respond to the eLetter from Dr Schmoelzer et al, regarding our paper entitled "Potential Hazard of the Neopuff T-Piece Resuscitator in the Absence of Flow Limitation".
Dr Schmoelzer et al have verified our findings that even an increase in flow from 5-15L/min will bring about a four-fold increase in PEEP, a serious potential hazard of the Neopuff. His failure to reproduce...
Dear Editor: The recent article of retrospective comparison of two methods, colour Doppler ductal diameter and pulsed Doppler flow pattern, as echocardiographic indicator for patent ductus arteriosus (PDA) treatment in preterm infants by Condo' et al was well-designed and interesting.[1] We agree the conclusions of that both methods are significantly associated, and may use as a cross check to assist in the management o...
It was with interest that I read the article by Whittaker et al regarding toxic additives in medication for preterm infants, particularly the assessment of alcohol intake in the infant population treated with furosemide oral solution. I was surprised by the statement “ethanol exposure in the preterm infants … ranged from 0.2mL to 1.8mL/ week uncorrected for weight, the equivalent of a 70kg man consuming between 1 and 7...
We were pleased that our findings [2] and those of Tunell's group [3] have been confirmed in the recent paper by van Vonderen et al [1], that is the inspiratory efforts of prematurely born infants coinciding with inflations during resuscitation at birth are critical in increasing the expired carbon dioxide levels. In addition, we have previously published the relationship between expired tidal volume and expired carbon dio...
Dear Editor, We read with great interest the article by Fumagalli et al.,1 who reported subcutaneous fat necrosis (SFN) in an infant suffering perinatal hypoxic injury and treated with total body cooling, which complicated by hypercalcaemia. In their report,1 it is suggested that total body cooling likely increase the risk of SFN and renal complications. Recently, we report a case of SFN, which complicated by hypercalcaem...
We read with interest the article by K Ganesan et al 1 about using prophylactic oral Nystatin to prevent fungal colonisation and invasive fungaemia. We strongly support this practice especially in preterm babies who are on broad spectrum antibiotics.
It is interesting to know if the authors discovered any other bacterial organisms apart from candida in there routine surveillance swabs. We in our unit in Royal O...
Dear Editor,
Phillips et.al (1) demonstrated the Neonatal Illness Prognosis Indicator (NIPI) to be a good predictor of mortality in very low birth weight neonates. We carried out a study replicating the design of the original research to evaluate the use of this newly developed scoring system in a different setting.
The study was based in Glan Clwyd District General Hospital, Boddelwyddan, which has...
We read with interest Laing’s article on controlling an outbreak of MRSA in a neonatal unit. We have also learnt from outbreaks on our neonatal unit. Laing et al talk about cohort nursing for those babies found to be colonised. In our experience it is important to isolate/cohort not just those babies that are MRSA colonised, but also to cohort those babies whom are known contacts, with MRSA swabs repeated weekly. It is i...
Dear Sir, First let me congratulate you for the phenomenal work that you have done at Safdarjung Hospital.
On reading your paper, I found discrepancies in numbers in the flow chart (Fig 1) and Table 2: viz. out of 1599 abnormal babies on pulse oximetry, Echo confirmed 18 major and 15 critical CHDs. However, further in the text and in table 2, the corresponding numbers are cited as 39 major and 22 critical CHDs...
To The Editor: I read the article by Tracy et al with great interest (1). However I would like to point out few issues that need explanation before the study results can be accepted. First, despite of more leak with one person method, the tidal volumes being delivered are not statistically different in both the groups. Hence, the superiority of this technique in decreasing the need of endotracheal intubation and chest com...
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