Clinical paperEndotracheal suction in term non vigorous meconium stained neonates—A pilot study☆
Introduction
Nearly 10–26% of deliveries are complicated by the passage of meconium of which 4–10% develop meconium aspiration syndrome (MAS)1, 2; of which nearly half require mechanical ventilation; 15–30% develop pulmonary air leaks and 5–12% die.3, 4 In addition, early onset neonatal seizures, hypotonia and cerebral palsy have been reported in neonates born through MSAF.5, 6, 7, 8
Several modalities have evolved in the antepartum, intrapartum and immediate postpartum period for prevention of MAS. Suctioning of the oropharynx and hypopharynx before delivery of shoulders and routine postnatal intratracheal suction of all infants born through MSAF was in practice until the last quarter of past century4, 9 which is currently not recommended.10, 11, 12 The results of a large multi-centric randomized clinical trial13 led to changes in neonatal resuscitation14, 15, 16 and tracheal suction was recommended only for depressed patients. Cochrane review17 on this subject too supported selective intubation for non-vigorous babies until further research is available. The implementation of new recommendations did not increase the incidence of meconium aspiration.18 Current evidence does not support or refute endotracheal suctioning of depressed infants born through MSAF.16 However, ET suction is still being advocated to clear the trachea of non-vigorous newborns at birth.20 This recommendation is based on consensus and past practice as there are no well conducted randomized controlled trials evaluating the role of ET suction in preventing MAS in non-vigorous infants. Aspiration can potentially occur in-utero,3 during or immediately after birth, and it would be unwise to expect that any postnatal method of suction would clear all of the meconium from the airway of the infant. Several studies have observed that despite employing all available current strategies to clear meconium from accessible proximal airways, incidence of MAS continues to remain unaffected.4 The effectiveness of endotracheal suction in non-vigorous newborns in preventing MAS and associated morbidity has never previously been evaluated in a randomized controlled trial and various guidelines have warranted further studies on this issue.14, 15, 19 In addition, the current practice of performing endotracheal suction delays the definitive steps of resuscitation by several seconds and is associated with potential side effects of bradycardia, hoarseness, stridor, apnea etc.13
Given the occurrence of in-utero aspiration of meconium, the potential harm of unnecessary endotracheal intubation and evidence in support of hypoxia-ischemia -asphyxia in the pathogenesis of respiratory disease in the meconium-exposed infant; the role of endotracheal suction in preventing MAS in non-vigorous neonates and its associated morbidities warrant systematic evaluation. This randomized clinical trial was designed to evaluate the effect of “Endotracheal suction” vs. ‘No endotracheal suction’ on occurrence of meconium aspiration syndrome (MAS) and/or all-cause mortality in non-vigorous neonates born through meconium stained amniotic fluid (MSAF).
Section snippets
Subjects and setting
This was an open label randomized controlled trial, conducted from 1st May 2012 to 31st August 2013 at Smt. Sucheta Kriplani Hospital, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, India. A total of 175 singleton, full term neonates (between 37 and 41 completed weeks) with cephalic presentation born through MSAF and who were non-vigorous at birth were included in the study. Of the enrolled neonates, 88 were randomized to intervention group (No-ET group) and 87
Results
Fig. 1 shows the trial flow of the study. Out of a total term birth cohort 18676 births over the period, 1176 mothers with meconium stained amniotic fluid were assessed for eligibility. A total of 175 neonates were randomized (after excluding 785 vigorous term infants, 4 still births, 142 neonates due to refused consent, logistic reasons for 51 neonates {neonates who could not be included when the randomization team was not available or reached the delivery room after the neonate's
Discussion
This pilot RCT evaluated the incidence of MAS and/or death in non vigorous neonates born through meconium stained liquor in ‘No ET suction’ and ‘ET suction’ group. Other outcomes including the incidence of air leaks, seizures, and duration of oxygen requirement, respiratory distress and hospital stay were also similar in the two groups.
We did not find any significant difference in the incidence of MAS and/or death. The overall incidence of MAS in our study was 26% to 32% in depressed neonates.
Conclusions
In non-vigorous neonates born at term through MASF, endotracheal suction does not appear to alter the incidence of MAS and/or death. There is a need for a multi-center trial to address whether the current practices and guidelines can be justified.
What's known on this subject
Resuscitation guidelines advocate endotracheal suction as a management strategy to clear the trachea of non-vigorous neonates born through MSAF but despite employing current strategies to clear meconium from accessible proximal airways, incidence of MAS continues to remain unaffected.
What this study adds
This study demonstrates that it is feasible to randomize non-vigorous infants born through meconium stained liquor to receive on not receive endotracheal suction. Although not performing endotracheal suction at birth in these neonates does not seem to adversely affect the incidence of MAS and/or death in this population, a larger study will be needed to fully evaluate the balance of risks and benefits.
Contributor's statements
Sushma Nangia: Dr. Nangia conceptualized and designed the study, drafted the initial manuscript, and approved the final manuscript as submitted.
Sushma Nangia, Arvind Saili: Drs. Nangia and Saili carried out the initial analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted.
Shyam Sunder, Ratna Biswas: Drs. Sunder and Biswas designed the data collection instruments, and coordinated and supervised data collection, drafted the manuscript, and approved the
Conflict of interest statement
This is to declare that we, the four authors of this manuscript have no financial disclosure to make and have no conflict of interest.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.05.015