Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis (NLS#865)

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Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis (NLS#865)

CoSTR Citation

Strand ML, Lee HC, Kawakami M, Fabres J, Nation K, Rabi Y, Szyld E, Wyckoff MH, Wyllie J, Trevisanuto D. Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis . [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, 2019 July 26. Available from: http://ilcor.org

Collaborators

Jeffrey M. Perlman, Khalid Aziz, Ruth Guinsburg, Maria Fernanda de Almeida, Vishal Kapadia, Sithembiso Velaphi, Lindsay Mildenhall, Helen Liley, Shigeharu Hosono, Han-Suk Kim, Tetsuya Isayama and Charles Christoph Roehr.

Methodological Preamble and Link to Published Systematic Review

The continuous evidence process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of available literature regarding the treatment of newborns born through meconium-stained amniotic fluid and non-vigorous at the time of delivery (http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019122778) conducted by Ms. Carolyn Ziegler, Toronto, Canada with involvement of clinical content experts. Evidence for neonatal literature was sought and considered by the Neonatal Life Support Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review: Reference not yet available

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs, and Time Frame)

Population: Non-vigorous infants born at ≥ 34 weeks’ gestation delivered through meconium-stained amniotic fluid of any consistency (non-vigorous defined as heart rate <100 bpm, decreased muscle tone and/or depressed breathing at delivery).

Intervention: Performing immediate laryngoscopy with or without intubation and suctioning at the start of resuscitation.

Comparison: Performing immediate resuscitation without direct laryngoscopy at the start of resuscitation.

Outcomes:

Survival to hospital discharge (Primary)

Neurodevelopmental impairment (Secondary)

Meconium aspiration syndrome (Secondary)

Other respiratory outcomes - continuous positive airway pressure or mechanical ventilation, treatment of pulmonary hypertension with inhaled nitric oxide, oral medications or extracorporeal membrane oxygenation (Secondary)

Delivery room interventions - cardiopulmonary resuscitation/medications, intubation for positive pressure ventilation (Secondary)

Length of hospitalization (Secondary)

Study Designs: Randomized controlled trials (RCT) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, and cohort studies) were included in the review.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) and animal studies were excluded. Literature search updated to May 2019.

A priori subgroups to be examined: Consistency of meconium (thin vs thick), gestational age categories (late preterm (34-36+6/7 weeks), term (37-40+6/7 weeks), post-term (≥42 weeks)), presence or absence of fetal bradycardia, route of delivery (spontaneous vaginal, instrumented vaginal, caesarean section), direct laryngoscopy with vs without suctioning.

PROSPERO Registration: CRD42019122778

Consensus on Science

For the critical outcome of survival to discharge, we have identified low certainty evidence (downgraded for inconsistency and imprecision) from 3 RCTs (Chettri 2015 1208, Nangia 2016 79, Singh 2018 ) enrolling 449 non-vigorous newborns delivered through meconium-stained amniotic fluid (MSAF) which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.99; 95% CI, 0.93-1.06; p=0.87; absolute risk reduction [ARR], -0.9%; 95% CI -6.4% to 5.5%, or 9 fewer patients/1000 survived to discharge with the intervention [95% CI, 64 fewer patients/1000 to 55 more patients/1000 survived to discharge with the intervention]).

For the critical outcome of cognitive neurodevelopmental impairment, we have identified very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) from 1 RCT (Chettri 2015 1208) enrolling 86 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.75; 95% CI, 0.37-1.50; p=0.41; absolute risk reduction [ARR], -8%; 95% CI -20% to 15.9%, or 80 fewer patients/1000 with mental neurodevelopmental impairment with the intervention [95% CI, 200 fewer patients/1000 to 159 more patients/1000 with mental neurodevelopmental impairment with the intervention]). The neurodevelopmental assessment from this one study was done at an early and non-standard time, hence the results are poorly predictive of longer-term outcomes. The effect of the intervention on neurodevelopmental impairment remains uncertain.

For the critical outcome of motor neurodevelopmental impairment, we have identified very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) from 1 RCT (Chettri 2015 1208) enrolling 86 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.91; 95% CI, 0.49-1.67; p=0.76; absolute risk reduction [ARR], -3.1%; 95% CI -17.4% to 22.8%, or 31 fewer patients/1000 with motor neurodevelopmental impairment with the intervention [95% CI, 174 fewer patients/1000 to 228 more patients/1000 with motor neurodevelopmental impairment with the intervention]). The neurodevelopmental assessment from this one study was done at an early and non-standard time, hence the results are poorly predictive of longer-term outcomes. The effect of the intervention on neurodevelopmental impairment remains uncertain.

For the critical outcome of hypoxic ischemic encephalopathy, we have identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 2 RCTs (Nangia 2016 79, Singh 2018) enrolling 327 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.86; 95% CI, 0.62-1.18; p=0.34; absolute risk reduction [ARR], -4.8%; 95% CI -13.1% to 6.2%, or 48 fewer patients/1000 with hypoxic ischemic encephalopathy with the intervention [95% CI, 131 fewer patients/1000 to 62 more patients/1000 with hypoxic ischemic encephalopathy with the intervention]).

For the critical outcome of meconium aspiration syndrome (MAS), we have identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 3 RCTs (Chettri 2015 1208, Nangia 2016 79, Singh 2018) enrolling 449 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.93; 95% CI, 0.73-1.19; p=0.57; absolute risk reduction [ARR], -2.7%; 95% CI -10.3% to 4.5%, or 27 fewer patients/1000 with MAS with the intervention [95% CI, 103 fewer patients/1000 to 45 more patients/1000 with MAS with the intervention]).

For the important outcome of use of mechanical ventilation, we have identified low certainty evidence (downgraded for risk of bias and imprecision) from 3 RCTs (Chettri 2015 1208, Nangia 2016 79, Singh 2018) enrolling 449 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 1.00; 95% CI, 0.66-1.53; p=0.99; absolute risk reduction [ARR], 0%; 95% CI -5.4% to 8.4%, or 0 fewer patients/1000 received mechanical ventilation with the intervention [95% CI, 54 fewer patients/1000 to 84 more patients/1000 received mechanical ventilation with the intervention]).

For the important outcome of use of respiratory support excluding mechanical ventilation, we have identified low certainty evidence (downgraded for risk of bias and imprecision) from 2 RCTs (Nangia 2016 79, Singh 2018) enrolling 327 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.99; 95% CI, 0.81-1.20; p=0.88); absolute risk reduction [ARR], -0.4%; 95% CI -7.3% to 7.6%, or 4 fewer patients/1000 received respiratory support excluding mechanical ventilation with the intervention [95% CI, 73 fewer patients/1000 to 76 more patients/1000 received respiratory support excluding mechanical ventilation with the intervention]).

For the important outcome of endotracheal intubation for PPV in the delivery room, we have identified low certainty evidence (downgraded for risk of bias and imprecision) from 2 RCTs (Chettri 2015 1208, Nangia 2016 79) enrolling 297 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 1.15; 95% CI, 0.83-1.59; p=0.40; absolute risk reduction [ARR], 4.1%; 95% CI -4.7% to 16.2%, or 41 more patients/1000 received endotracheal intubation in the delivery room with the intervention [95% CI, 47 fewer patients/1000 to 162 more patients/1000 received endotracheal intubation in the delivery room with the intervention]).

For the important outcome of chest compressions in the delivery room, we have identified very low certainty evidence (downgraded for risk of bias and imprecision) from 3 RCTs (Chettri 2015 1208, Nangia 2016 79, Singh 2018) enrolling 449 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 1.13; 95% CI, 0.40-3.20; p=0.82; absolute risk reduction [ARR], 0.4%; 95% CI -1.9% to 6.8%, or 4 more patients/1000 received chest compressions in delivery room with the intervention [95% CI, 19 fewer patients/1000 to 68 more patients/1000 received chest compressions in the delivery room with the intervention]).

For the important outcome of use of epinephrine in the delivery room, we have identified very low certainty evidence (downgraded for risk of bias and imprecision) from 3 RCTs (Chettri 2015 1208, Nangia 2016 79, Singh 2018) enrolling 449 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR,1.62; 95% CI, 0.37-7.05; p=0.52; absolute risk reduction [ARR], 0.8%; 95% CI -0.8% to 8%, or 8 more patients/1000 received epinephrine in delivery room with the intervention [95% CI, 8 fewer patients/1000 to 80 more patients/1000 received epinephrine in the delivery room with the intervention]).

For the important outcome of treatment of pulmonary hypertension (iNO, medications, ECMO), we have identified very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) from 1 observational study (Chiruvolu 2018 e20181485) enrolling 231 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (RR, 0.52; 95% CI 0.15-1.79; p=0.30; absolute risk reduction [ARR], -2.9%; 95% CI -5% to 4.7%, or 29 fewer patients/1000 received treatment of pulmonary hypertension (iNO, medications, ECMO) with the intervention [95% CI, 50 fewer patients/1000 to 47 more patients/1000 received treatment of pulmonary hypertension (iNO, medications, ECMO) with the intervention]).

For the important outcome of length of hospitalization, we have identified very low certainty evidence (downgraded for risk of bias, inconsistency and imprecision) from 2 RCTs (Nangia 2016 79, Singh 2018) enrolling 327 non-vigorous newborns delivered through MSAF which showed no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy (mean difference, 0.5 days lower; 95% CI, 1.76 days lower to 0.75 days higher; p=0.43).

Treatment Recommendations

For non-vigorous newborns delivered through meconium-stained amniotic fluid, we suggest against routine immediate direct laryngoscopy after delivery with or without tracheal suctioning when compared to immediate resuscitation without direct laryngoscopy. Meconium-stained amniotic fluid remains a significant risk factor for receiving advanced resuscitation in the delivery room. A provider may perform intubation and tracheal suctioning to relieve airway obstruction.

Justification and Evidence to Decision Highlights

The Task Force recognizes that, while the Treatment Recommendation has not changed, several studies have been added to the literature since the last recommendation was made. While these studies contribute new evidence regarding this topic, the certainty of the findings remains low or very low due to the difficulty of performing unbiased studies of this clinical question as well as failure of the data to reach optimal information size.

In making this suggestion, we place value on both harm avoidance (delays in providing bag-mask ventilation, potential harm of the procedure) and the unknown benefit of routine tracheal intubation and suctioning.

Routine suctioning of non-vigorous infants is more likely to result in delays in initiating ventilation, especially where the provider is unable to promptly intubate the infant or suction attempts are repeated. In the absence of evidence of benefit for suctioning, the emphasis should be on initiating ventilation within the first minute of life in non breathing or ineffectively breathing infants born through meconium-stained amniotic fluid.

Knowledge Gaps

Despite the addition of several randomized trials focused on this clinical question, the optimal information size is not achieved even with all of the studies taken together. The difficulties of performing a study while minimizing the risks of bias due to difficulty with blinding and assessment of outcome make accrual of evidence a significant challenge. The priorities for study remain similar to previous versions of the CoSTR:

  • Does the potential for harm (i.e. delay in starting posititve pressure ventilation or transient bradycardia/hypoxia, mortality, NDI) outweigh the potential for benefit (i.e. reduction of MAS, need for mechanical ventilation or treatment of pulmonary hypertension)?
  • Do risks or benefits of intubation with tracheal suctioning vary with any subgroup (gestational age, thickness of meconium)?
  • Long-term outcomes should be included in future studies.
  • The neurodevelopmental, behavioral, or educational assessment for future studies should be at or after 18months of age and completed with a validated tool.

Attachments

Evidence-to-Decision Table: Should ETT suction vs. No ETT suction be used for non-vigorous infants: a systematic review and meta- analysis?

References

Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. J Pediatr 2015;166:1208-13.

Chiruvolu A, Miklis KK, Chen E, Petrey B, Desai S. Delivery room management of meconium-stained newborns and respiratory support. Pediatrics 2018;142(6):e20181485.

Nangia S, Sunder S, Biswas R, Saili A. Endotracheal suction in term non vigorous meconium stained neonates—a pilot study. Resusitation 2016;105:79-84.

Singh SN, Saxena S, Bhriguvanshi A, Kumar M, Chandrakanta, Sujata. Effect of endotracheal suctiooing just after birth in non-vigorous infants born through meconium stained amniotic fluid: A randomized controlled trial. Clin Epid and Global Health 2018. https://doi.org/10.1016/j.cegh.2018.03.006



Discussion

GUEST
Allen Fischer (102 posts)
Thank you for doing this work. "Very low certainty evidence" exceeds the value of the anecdotes that resulted in the practice of immediate tracheal suctioning in the first place. Immediate tracheal suctioning delays the resuscitation of these non-vigorous infants at a time when every second counts.
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GUEST
Linda Slater-Myer (102 posts)
Agree with the author's treatment recommendations
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Eva Carrizales DO, MPH (102 posts)
We have not had any cases of MAS after we stopped suctioning vigorous infants with hx of meconium . Our mec babies were Tx with BCPAP if needed, and recovered well.
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GUEST
Steven Ringer (102 posts)
This is comprehensively written and the identification of areas of needed research is extremely valuable in highlighting the real gaps
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GUEST
Rita Prasad Verma (102 posts)
Agree with the evidence based recommendations as above. My only comment is as follows. Suctioning out the gastric fluid after resuscitation in depressed infants born through meconium stained amniotic fluid should be considered as the gastric contents may be meconium stained and get aspirated into the lungs espy in non intubated babies . The possibility may not be high and there is not much literature on it but this potentially is a clinical set up worth considering or looking into in future studies.
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GUEST
Venkataraman Balaraman (102 posts)
Although we acknowledge the lack of evidence, by coming up with recommendations which are not strongly worded opens the door to continue nebulous practice and as such inability for us to truly understand the impact of these recommendations in the clinical practice situation
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Maureen Sims (102 posts)
The data to not suction are weak. I have observed and reviewed several deliveries with non-vigorous meconium stained babies. I have found suctioning to be helpful in the delivery room. SInce the new standards were in place, I have witnessed more issues after birth in the NICU. I think the motive to eliminate this step (suctioning) was more to protect hospitals for not having trained providers in the delivery room in cases of meconium stained fluid. Better to educate and train than keep dumbing down the standards. PLEASE AAP stop diluting the standards to appeal to the least common denominator. Having practiced neonatology for decades, I notice this is happening. Hold the line please.
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Steven Gwiazdowski (102 posts)
I would like to see outcomes relating to intubation stratified by "experience." I was trained in an era when all meconium stained infants (rightly or wrongly....mostly wrongly) were intubated. I wonder if, for those neonatologists that are still ACTIVELY practicing CLINICAL medicine, if their time to successful intubation and their percentage of successful first time attempts are higher than more junior practitioners that were trained in an era of decreased intervention (read - have had much less reps with intubation). That said, I wonder if ILCOR should look into these demographics and consider language that takes this into account (if the data supports that currently clinical active practitioners whose training occurred in the "intubate all meconium infants" are more adept at intubating than those practitioners who were trained in the "post- Wisell" era.
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Susan McClanahan (102 posts)
After 40 years of neonatal nursing I knew this recommendation for "no tracheal suctioning" was not a good recommendation. I have always thought at least one suction pass was best and then intubation if necessary for time restraints. But NO suctioning was a bad idea for non-vigorous infants with thick meconium. I would like to see the recommendation be for one tracheal suction pass, and then intubation if needed. Several passes will delay intubation and possibly not clear the airway that much better, and no suctioning is not a good practice.
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GUEST
Kathryn McLean (102 posts)
Would be interesting to study if bulb suctioning of oropharynx upon delivery of head (not entire body) made any difference. In past I found very few infants who responded by taking a breath during that process as the chest was compressed during labor, but made PPV easier as airway clearer.
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GUEST
Jane M Carlson (102 posts)
I completely agree here. I postulate the vagal effect of suctioning and post delivery direct tracheal intervention only worsens the low heart rate, making it more difficult for the infant to recover.
GUEST
Tracey Hill (102 posts)
I do think it is important to emphasize the importance of suctioning via ET tube during MR SOPA corrective steps in infants delivered trough meconium stained fluid, even if we will not routinely intubate to suction prior to any other resuscitative measures.
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GUEST
Janice Pettinato (102 posts)
If the ET suction is quick and efficient with no loss of HR. Then it should be done. If this cannot be guaranteed, and it most likely cannot, then resuscitation should start immediately.
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GUEST
Nirupama Laroia (102 posts)
The studies reflect our current clinical experience. Since stopping routine suctioning for meconium, we have seen less babies with meconium aspiration and certainly less with PPHN related to meconium and ECMO for meconium aspiration. The disease has certainly not disappeared but far fewer babies are extremely sick. I am glad that the recommendations are not going to change.
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Nathan Sundgren (102 posts)
A fair assessment of the available literature. I agree with no changes to the current recommendations.
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Caroline MCDonald (102 posts)
Since the NRP statement was publicized I have been concerned about the absolute interpretations of the wording “ROUTINE suctioning is no longer RECOMMENDED” in the depressed infant born through MSAF. In our institution it was taken as an absolute, that no baby should EVER be suctioned below the cords and those of us with many decades of experience who are expert intubators were rebuked harshly for doing so. I am very concerned that the statement has been taken too literally and that it should be reworded in such a way as to give an experienced provider the option without subsequent scorn.
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Jennifer Frame (102 posts)
I agree as an RN and NPR instructor in a smaller hospital where intubation is not always immediately available.
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Laureen LATTIN (102 posts)
I am disappointed that this protocol will remain unchanged. Although I do not have a study to back up my thoughts, I have been a NICU Nurse for 36 years, and a NRP Instructor for 30 of those years. I have seen many babies saved the prolonged and difficult healing process from MAS because they received direct visualization and suctioning, after being born through particulate meconium and are non-vigorous with HR <100 (or absent). When particulate meconium, which is in the airway, is blown into the chest with PP ventilation, healing is much more difficult. We have an experienced incubator at every MSAF delivery. We never intunate/suction vigorous infants. I continue to advocate for direct visulization/ suction of the sickest MSAF infants.
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GUEST
Dee Gala (102 posts)
Thank you for submitting an early recommendation for this important issue! I agree with the new /revised statement. As a pediatrician working at the bedside and present for deliveries, I agree there is a real potential for delay in vital PPV with multiple ETT intubation and suctioning attempts. I’ve worked under both systems and believe infants get more prompt airway / breathing assistance with the more direct path of offering PPV immediately.
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Janet Lindquist (102 posts)
I have been working with neonates for almost 40 years and I have found that infants that get intubated and their airway cleared do much better. I listen to what they sound like and the difficulty they have with breathing and make my decision on their stats. I understand that if you do not have someone that is good at intubation, it can waste valuable time. However, if you have capable staff for intubation, the infant recovers much faster and a lot of them do not need to have prolonged stays in a level II or III because of an effective resuscitation.
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GUEST
Mosarrat Qureshi (102 posts)
I agree with the findings of the review
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Joseph Garcia-Prats (102 posts)
It appears that there is no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy after reviewing the data that is available.
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GUEST
Thuman Merritt (102 posts)
The science and current clinical trials are insufficient to make the recommendation of NO intubation and suctioning of a non vigorous infant. With a NRP provider who is skilled at intubation there is minimal delay in the initiation of effective ventilation in accordance to NRP guidelines. By not intubating and removal of meconium in the hypopharynx there is a chance of introducing additioanal meconium ino the tracheal and airways resulting in airway obstruction and inflammatory pneumonia and increased risk of airleaks. In the absence of high quality data regarding intubation and sucking it is inadvisable to may such a strong recommendation of not providing airway inspection and the option for suctioning. The absence of high quality data will continue until an appropriate RCT is conducting comparing one strategy versus the other. As meconium presence in the AF is a risk factor for poorer outcome, and is usually known prior to delivery there is ample opportunity to obtain consent from the mother for either option depending on randomization. The data presented do not give the number needed to harm if intubation is performed and meconium is suctioned in non-vigorous newly born infants. An appropriately powered RCT with appropriate outcomes is critical. Why make inappropriate recommendations when the data are lacking?
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Kristin Steuerle (102 posts)
Back in 2000, when I started as a pediatric resident, I asked my senior resident why we intubated for meconium, since it seems to go against the fundamental principle of NRP, which is to avoid secondary apnea. He told me the only reason we do it is because we need the practice (even though that was the guideline at the time). It seems that this is one of those medical practices that someone thought up that then people continue to hold onto. I realize the evidence isn't great, but I am not sure why we need to continue to explore this question further. Glad to see that the task force did take on the job of reviewing the new articles for me and reaffirming their statement.
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Rita C SILVEIRA (102 posts)
The routine suctioning of non-vigorous infants after meconium aspiration can be perfomed once and both, tracheal suction and intubation must be a priority in these cases .
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Lloyd Jensen (1 posts)
Thanks for going through the process . It can be very difficult.
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GUEST
Richard Hearn (102 posts)
It is good to see increasing evidence steering us away from a historical practice that delays definitive management of the airway of infants who predominantly have low tone rather than any form of obstruction. Opening the airway through good non-invasive techniques or with adjuncts (including ETT where necessary) is the key to improving outcome. Delay in this, from whatever route, has the potential to be to the detriment of the infant. In the rare event of airway obstruction this will rapidly become apparent from initial manouevres and direct visualization and more advanced airway techniques can be instituted at this point.
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GUEST
George Powers (102 posts)
There still appears to be quite divergent opinions on tracheal suctioning of the meconium- stained non-vigorous infant due to experience and the relative paucity of newer data. Having been a pediatrician for almost 30 years, I have taken part in many such resuscitations and a small number of babies required tracheal suctioning of meconium to be able to move any air into and out of the lungs. Despite the small number, it truly made a difference in those instances. A statement should be added that when you reach intubation due to lack of response of your initial resuscitation and obstruction is apparent that suctioning should be done prior to providing PPV through the ETT, preferably using a meconium aspirator connection.
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GUEST
Brenda Morrill (102 posts)
Thank you for going through this investigative process. As an RN of 37 years and a NRP instructor for 25 years I agree. I am employed in a large University Medical Center and not using tracheal visualization/suctioning of non-vigorous infants (MAS babies) has not changed outcomes. If a MAS infant was placed on ECHMO there were also other factors contributing to this procedure.
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GUEST
Shah Hossain (102 posts)
Agree with the authors. Tracheal suctioning delays resuscitation in the babies that needs it the most.
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JOSE GRANZOTTO (102 posts)
I think that a once suction with laringoscopy before resuscitation provide a better ventilation.
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Clarice Adelaide Graça (102 posts)
Eu concordo com as recomendações atuais do Ilcor
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D. Anna Jarvis (102 posts)
Appreciate the lack of large enough studies to make stronger recommendations. Urgent need for a multicenter RCT to inform "best practices". Until then I suggest (for non-vigorous babies with meconium staining) "One endotracheal suction attempt to clear particulate meconium, then ventilatory support as needed".
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GUEST
S Frederick (102 posts)
In modern medicine the lowest common denominator is that deliveries are not always occurring at delivery centers with highly experienced individuals capable of rapid and accurate intubation. Training for intubations has decreased and many more infants are managed without invasive ventilation. For those that work at training hospitals, many have noticed the confidence, skill level, exposure and experience for trainees has decreased and diluted. Pediatric residents who will become pediatricians and neonatologist do less NICU service time and have less opportunities for procedures with the increase in trainees. NNPs students are nurses that have less time with NICU and delivery room exposure prior to training with some programs accepting individuals with as little as 1 year of bedside nursing. PA programs are increasing and many having very little to no neonatal experience prior to starting a PA Neonatal residency. All of this has lead to a decrease in the necessary skills to rapidly assess and perform the critical procedure of intubation because of the increasing pool of trainees and the combined diluted experience they have prior to starting. They then have a relatively short period of time to acquire that skill to the proficiency that some people have been doing for 10-20 years. There was a time when an individual could perform 5 intubations in a day, now they may struggle to perform 5 intubations a month. We need to look at this globally and remove ourselves from the scope of our primary institutions or from our experience level and ability to intubate. We must consider the 6 Bed Special Care Nursery covered by a moonlighting pediatrician with no respiratory therapist or NNP to assist overnight just as much as 60 bed Level III delivery unit with 2 neonatologist on at night with a handful of experience NNPs. Globally the skill level has been diluted by shifts in how we train and practice medicine and its difficult to address; its a good thing when an infant doesn't need the unnecessary procedure of intubation but a bad thing when a provider can't successfully perform the act rapidly on a single attempt. There is no NRP requirement for a provider to be "highly skilled" so we can't make the assumption that all providers are "highly skilled". The best we are left for is providing a generalized recommendation based off the imperfect data that exist. The only way the get the true answer to what is best is a RCT with enough power to answer all of our outcome questions AND looking at the providers' skill level, duration to intubation, number of attempts, etc; unfortunately that is unlikely to happen due to multiple factors.
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GUEST
Ana Paula Figueiredo Leão (102 posts)
Conflicts of interest: Financial relationships
I belive that trachea aspiration of the newborn that is born bathed  in meconium liquid and not vigorous, should be performed.  After not responding to Positive Preassure Ventilation with mask and there is need to be intubated for better ventilation of the lungs 
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GUEST
Eliane Valtes (102 posts)
Concordo com tudo, não acho necessário nenhuma alteração
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GUEST
Aurimery Chermont (102 posts)
After 33 yearas of neonatal doctor the recommendation for "no tracheal suctioning" was not a good. for me at least one suction pass was best and then intubation if necessary . But as Susan posted above NO suctioning IS vertiam a bad idea for non-vigorous infants with thick meconium. I suggest That The recommendation should be for one tracheal suction pass, and then intubation if needed. Os clean that Will be Several passes delaying intubation and possibly not clear the airway that much better,. AGAIN no suctioning is not a good practice.
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GUEST
Luiz Henrique Gamba (102 posts)
The routine suctioning of non-vigorous infants after meconium aspiration can be perfomed once and both, tracheal suction and intubation must be a priority in these cases . The same like Rita.
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Fabio Cardoso (102 posts)
Meconium visualization laryngoscopy and it´s rapid aspiration facilitated resuscitation. We observed in our service that professionals continued to aspirate trachea without delaying the resuscitation result. I particularly adopted the practice of not aspirating trachea and observed that its evolution was more pronounced in the NICU. We had an increase in the milder cases of meconium aspiration syndromes. I disagree with the new guidelines on postponing tracheal aspiration in these cases.
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David Chen (102 posts)
Agree that the wording and recommendations appear to be an accurate reflection of the current state of evidence. Well done.
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Jonathan Wyllie (102 posts)
Thank you to all the colleagues who have already commented and to those who intend to do so. The the ILCOR Neonatal task force will look at all comments made. We intend to derive themes from comments and subsequently review and revise as appropriate based on the themes raised and the evidence quoted. However, the whole purpose of the ILCOR/GRADE process has always been to assess the available evidence. We are not able to make changes based upon anecdote, although recommendations and guidelines do not preclude experts making treatment decisions appropriate to individual cases as long as they can be justified. Again thank you all for this great feedback and engagement. Jonathan Wyllie Vice Chair Neonatal Task Force
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Sameer Wagle (102 posts)
The scientific evidence points to the fact that mortality in babies born through meconium stained AF is not related to amount of meconium below the vocal cords but to PPHN from intrauterine hypoxia and vascular remodeling. The morbidity however is related to amount of meconium aspirated and partly can be reduced by prompt suctioning of airway and trachea if possible. But that leads to the delay in initiating the PPV and further delay in return to spontaneous respirations. Since the delay in resuscitation has more harm in causing prolonged hypoxia and brain injury than meconium aspiration pneumonitis, I agree with authors conclusion that in absence of evidence of benefit of routine tracheal suctioning and laryngoscopy, PPV should be offered first after quickly clearing the oropharynx of meconium without visualization.
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Carmen Elias (102 posts)
Agree with the author's treatment recommendations
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Rangasamy Ramanathan (102 posts)
I agree with not performing "routine suctioning" . But, in depressed babies with pea-soup like meconium covered baby, one may be consider to intubate and suction once at least. If HR is low, then, continue with PPV via the ET tube. One will need a large RCT to prove or disprove the benefit vs. potential risk of intubation and suctioning. I do not buy the argument that lack of experienced people to intubate is a reason for not intubating. As NRP instructors, We should teach and help maintain competency with intubation. Intubation and establishing an airway is one of the most critical procedures any care provider attending a high risk delivery should be able to perform. One may use video assisted intubation to hep with successful intubation. This will still need oropharyngeal suctioning to visualize vocal cords.
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Chris McKinlay (102 posts)
I fully agree with the CoSTAR and a prima facie position of primum non nocere, until there is evidence that an invasive intervention is actually beneficial. One minor point; "cognitive" is preferred to "mental" development.
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Brad Goldenberg (102 posts)
I thank CoSTR for attempting to wrap our heads around how to approach a non-vigorous infant that is meconium-stained. HOWEVER, what we fail to do in each individual case is to assess the degree of meconium airway obstruction on first glance, that needs to be overcome quickly to proceed with air exchange. How is that done ? Only by direct laryngoscopy and suctioning if necessary, by a skilled and efficient intubator ! Since the only people well-trained enough are skilled practitioners( MD, RN, RRT'S) that are familiar and efficient at quick intubations, we are left making separate recommendations for those of us who can get in and out before delaying precious time to get air exchange going, and those of us who are not that efficient. I have struggled with how to approach this in the best way to be fair to both, but must admit there is none. If you need to ventilate, even though you are blowing meconium down an airway, I must accept the fact that this will cause much less CNS damage and morbidity in the long run than making less-skilled intubators struggle with clearing an airway for the best respiratory outcome - am I making sense ?
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Sílvia Raquel Milman Magdaleno (102 posts)
I think that just a one suction with laringoscopy before resuscitation provide a better ventilation with less obstruction of airways
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Claudia Barreto (102 posts)
A aspiração traqueal não é um procedimento rápido em mãos pouco experientes. E isso pode retardar a ventilação e reanimação, além de traumática. O mecônio pode ser aspirado apenas em Via Aéreas Superiores, como outras secreções, de acordo com os passos iniciais, facilitando e auxiliando o início da ventilação. Em casos específicos, com secreção muito espessa que esteja atrapalhando a ventilação, ai sim, aspiração traqueal. Acredito que as recomendações atuais ainda são pertinentes.
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Ahmed Moussa (102 posts)
Agree with the wording in this document. Appreciate that the team has well revised the available data. This is not a simple issue, but erring on the safe side as this is worded is good for me. Thank you!
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Richard Taylor (102 posts)
Good Work: The limited evidence available still doesn't support laryngoscopy and routine tracheal suctioning for non vigorous infants with mec stained fluid. But there are still unanswered questions regarding suctioning: should non vigorous infants born through meconium be suctioned (mouth and nose-blind) at the moment of birth, or after being brought to warmer or after attempting PPV as part of MRSOPA? Or should oral suction be limited to what ever is required to visualise the cords during intubation?
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Leeanne Lauzon (102 posts)
Agree with the authors' recommendations based on the evidence available thus far. Appreciate the clarification offered by Jonathan Wyllie: "recommendations and guidelines do not preclude experts making treatment decisions appropriate to individual cases as long as they can be justified".
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Natalia Restrepo (102 posts)
I believe that even thought the evidence is not what we would like for these types of recommendations in neonatal resuscitation, and working with newborns in a middle income country (Colombia) as a neonatologist for the past 25 years were we do have a high amount of meconium stained liquid, the recommendation of not aspirating and starting positive pressure ventilation has been easier for us in clinical practice and in training, and we have better outcomes in our babies.
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GISELDA SILVA (102 posts)
concordo que a ventilação inicial antes da aspiração direta da traqueia ,para aqueles que não têm boa prática de intubação, num bebê instável deve ser sempre considerada, porém nos bebês ativos,deve-se aspirar apenas o orofaringe. aguardamos novas recomendações.
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Gustavo Pelligra (102 posts)
Agree with the author's recommendations. Now it's up to NRP and other educational programs to figure out how to incorporate these recommendations in the resuscitation algorithm. Since we move away from routine intubation and suctioning, some practitioners wonder if the practice of routine oropharyngeal suctioning either at perineum or soon after delivery should be reevaluated. Although some studies showed no benefit in then past, they were conducted in an era where routine intubation and tracheal suctioning were routine. Thanks!
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Daniela Medeiros (102 posts)
I agree to immediate resuscitation without direct laryngoscopy.
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Neil Boyce (102 posts)
Interesting findings and this certainly reflects the available data and prompts for a more thorough study to be done. I am torn as a therapist (RRT) as I have been in the NICU environment 26 years now and I have seen good outcomes from both sets of guidelines (latter vs present) I think that a judgement call at the bedside must be made depending on so many variables. This critical thinking skill is declining over time with the next generation of therapists, nurses and yes, physicians. I support more investigation and data, as evidence based guidelines have been working well so far, let's keep it moving forward and put recommendations together that don't "can" the practice of delivering babies.
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Tsu Yeh (102 posts)
In fact I have our own opinion and I gave lectures in China, japan and in Europe. My opinion is based on physiology and not by clinical data, because the clinical data usually based on a lot of variation in: who resuscitate the baby, resident, attending, nurse, with different experience, in particular, the experience with endotracheal intubation. As you know, majority of the infant aspirated meconium before birth, many infants are born by C-section and already have MAS right after birth. Only small proportion, and perhaps, insignificant amount of Meconium aspirated during the second stage of labor. Once meconium already aspirated, it is essential to do ET suction and clean the upper airway as early as possible because meconium would migrate to periphery, e.g. in 2-3 hours with respiration, as seen in animal experiment regardless if there is a vigorous or non-vigorous. In fact, with vigorous cry, it may even enhance the migration speed of meconium to periphery. Thus, it will even cause more problem because if meconium migrate to periphery, respiration will get worse. Therefore, we recommend, if baby has respiratory distress shortly after birth, suggesting aspiration, we do recommend ET suction as soon as possible after birth regardless if he infant is vigorous or not. Of course, ET intubation should be done by person with experience so that cyanosis or bradycardia will not occur. There are two papers, and one chapter from my book clearly demonstrated this. (Neonatal Med 2017 May;24(2):53-61. . NeoReviews 2010;11:e503-e12. ) If my suggestion is well taken, please cite my paper as credit.
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Carlos Zaconeta (102 posts)
we observed no difference in outcome after we stopped aspirating trachea in these babies.
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Oliva Ortiz-Alvarez (102 posts)
I agree with the recommendation. I would like to see an analysis stratifying for the size of the centre where the resuscitation happened. Based on the comments posted I see that the common theme is the presence or not of an experienced resuscitator. The frequency with which such resuscitator performs the tracheal intubation to keep the skill adds weight to the recommendation of proceeding with PPV after clearing the mouth particularly in small centres. Although I have no data to support this comment.
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Richard Taylor (102 posts)
Agree with the recommendation although I do have a concern with loss of clinical skills. Another question is regarding blind (oral/nasal) suctioning for babies born through mec: should suctioning be done at the moment of birth, after being brought to warmer, after attempting PPV as part of MR SOPA or just in order to visualize the cords if baby need to be intubated?
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LEILA PEREIRA (102 posts)
I agree with the new recommendations. For a procedure to be considered routine there needs to be evidence of benefits. In this case, aside from having no benefit, it may delay the start of ventilation, the benefit of which has been clearly established. I also agree with the authors' decision to consider individualized management of tracheal aspiration in some cases, since the available evidence on the topic are either of low or very low quality.
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Carlo Dani (102 posts)
First of all I want to thanks colleagues who carried out this important job. The limited availability of sized RCTs makes difficult to sustain firm recommendations on this topic. However, I think that the suggestion against routine immediate direct laryngoscopy in non-vigorous infants after delivery with or without tracheal suctioning can be accepted on the basis of current evidences. In fact, when we speak of "routine" laryngoscopy we do not exclude that it can be performed in particular situations (i.e.: in severely ill patients or in case of particulate meconium ) that could be detailed in local protocol taking into account the local experience of personnel.
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Susan Greenleaf (102 posts)
I agree with the finding and support the new recommendation from the group. This will make infants safer and have less trauma related to intubation. Thank you for always supporting the smallest patients.
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Andrea Lübe (102 posts)
I agree not to perform tracheal aspiration if the airways are not obstructed. In our delivery room care experience, many colleagues wasted time attempting intubation, delaying the onset of positive pressure ventilation, and worsening the neonate's neurological prognosis.
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Poornima Murthy (102 posts)
Agree with current recommendations. We have not seen any increased incidence of MAS or PPHN with these recommendations
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Gregory Moore (102 posts)
I agree with the comments that have the sentiments seen in the above comments of Jonathan Wyllie, Ahmed Moussa and Leeanne Lauzon. The evidence doesn't support or refute this historical practice of intubation/suction with perfect clarity. Given this is the difficult reality, the task force did a solid job and provided a recommendation that supports no routine suctioning but allows for individual use of suctioning on a case-by-case basis.
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Rich Ormonde (102 posts)
This is great. I hope this translates into commonsense guidelines that will be taught both sides of the Atlantic in the same order.
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Brigitte Lemyre (102 posts)
I agree with the recommendation, as the wording leaves room for individual assessment while removing the idea of routine.
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Danielle Nardi (102 posts)
I think more prospective studies should be necessary to show more outcomes. Ventilation is the most important thing to the newborn, but if the meconium is obstructive, i think it should be suctioned.
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Josiane Trafane (102 posts)
In my point of view , there aren’t scientific evicences that the procedure of intubation/suction is inadequate. Therefore I’ll continue practicing the current recommended methodology
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Júlio César Veloso (102 posts)
Concordo com as novas recomendações. Tambem não vimos nenhum aumento da incidência de MAS ou HPP com elas. Acredito que sucção rotineira de lactentes não vigorosos após a aspiração de mecônio pode ser realizada uma vez e, tanto a sucção traqueal quanto a intubação devem ser analisadas caso a caso.
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James Pribble (102 posts)
Agree with the recommendations given the evidence that is presented. Appreciate the discussions from experienced neonatal providers, but at present the evidence points towards no advantage for immediate DL in non-vigorous infants with or without tracheal suctioning. These are recommendations and as the evidence is low, discretion is still in the hands of the providing physician.
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Dora Stinson (102 posts)
Meconium in the amniotic fluid is a flag for increased risk to the depressed baby at birth, and the time for suctioning will vary. The key is to be prepared to suction below the cords if the airway is obstructed - with laryngoscope, endotracheal tube, suction, meconium adapter - when needed; this may be initially, or after going through the steps of MRSOPA. The wording of the current recommendation does allow this.
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James Cummings (102 posts)
Excellent update. Balanced and rigorous. Recommendations allow for individual decision-making.
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Luis Miranda (102 posts)
Congratulations for the outstanding work. The results of the doing the systematic review and meta-analysis studies made me be convinced that it is about time to stop doing (regular) tracheal intubation and aspiration on every non-vigorous newborn.
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Luis Eduardo Miranda (102 posts)
Taking into consideration the results of the systematic review and the meta-analysis, and until future RCT´s prove oyherwise, I think it is about time to stop recommending routine tracheal intubation and aspiration in every non vigorous baby born with meconium-stained amniotic fluid. Being a NRP instructor in Brazil for a long time, I have testified the great difficulty most of the trainees have to perform intubation in 20 seconds and in his first attemp. It sounds better to teach how to ventilate properly these babies rather than wasting time trying to intubate.
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DAIHAI CHOI (102 posts)
The data(do not intubation and do not suction) are weak. I alway knews intubation and suctioning to be helpful in the delivery room or ER. and I have found that infants that get intubated and their airway cleared do much better. I understand that if you do not have someone that is good at intubation, it can waste valuable time. if you have capable staff for intubation, the infant recovers much faster and a lot of them do not need to have prolonged stays in intensive care unit for long because of an effective resuscitation. and also the motive to eliminate this step (suctioning) was more to protect hospitals for not having trained providers in the hospital in cases of meconium stained fluid. Better to educate and train than keep dumbing down the standards.
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ANA CLAUDIA SOARES (102 posts)
We agree with current recommendations. These studies reflect our current clinical experience. In my hospital we have not seen any increased incidence of MAS or PPHN with these recommendations. We have no control about long-term outcomes as they follow up in private clinics and we don't have a unified system of clinical information
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Nell Tharpe (102 posts)
Agree with author's recommendations. It would be useful to clarify that all nonvigorous infants with meconium should be gently suctioned to remove meconium from oropharynx and hypopharynx before stimulation, using the suction method that is within the scope of practice of the individual providing care to the infant. This may be performed with a suction catheter, bulb syringe in the cheek, or ET based on clinical experience and competence. When intubation is obviously needed for the most depressed neonates then brief suctioning can be done prn if there is visible meconium to allow clear passage of an ET tube as needed for optimal ventilation. Many practitioners practice in community settings and nurses may be the first to begin the initial steps. This clarification based on scope of practice and competency can aid in directing actions in each clinical setting. The key message is that all non-breathing infants (meconium and clear fluid) should be suctioned before PPV, with suctioning being brief and gentle, and followed by the rest of the initial steps before initiation of PPV.
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Sook Kyung Yum (102 posts)
I think routine laryngoscopy with or without intubation is not necessarily a "must-be-done-immediately" procedure in the non-vigorous newborns with MSAF, but current recommendation somewhat sounds as if this procedure should be strongly restricted. There is not enough scientific evidence that can support this recommendation as a one-fits-all methodology in various delivery settings around the world. In hospitals with experts in intubation procedure, there would be not much delay in establishing adequate PPV. Rather, in some circumstances, PPV without suctioning way exacerbate airway obstructions. Hence the recommendation should be more clear on the possibility for case-by-case decision, and present laryngoscopy with or without intubation as an acceptable (though not routine) option.
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Su Jin Cho (102 posts)
I agree with the recommendation because routine suctioning of non-vigorous infants is more likely to result in delays in initiating ventilation. Thank you for reviewing the recent publications.
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Eduardo Serour (102 posts)
I believe in the benefit of tracheal aspiration as an important procedure in airway clearance before VPP. And based on everyday evidence, I maintain this conduct.
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