Recent discussions
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Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
Agree with the author's treatment recommendations -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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 -
Виктория Антонова
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.