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Background: Recently, the International Liaison Committee on Resuscitation published a systematic review that concluded that routine suctioning of clear amniotic fluid in the delivery room might be associated with lower oxygen saturation (SpO2) and 10 min Apgar score. The aim of this study was to examine the effect of delivery room airway suctioning on the clinical appearance, including muscle tone and skin colour, of video-recorded term and preterm infants born through mainly clear amniotic fluid. Methods: This was a single-centre observational study using transcribed video recordings of neonatal stabilizations. All infants who received delivery room positive pressure ventilation (PPV) from August 2014 to November 2016 were included. The primary outcome was the effect of airway suctioning on muscle tone and skin colour (rated 0–2 according to the Apgar score), while the secondary outcome was the fraction of infants for whom airway suction preceded the initiation of PPV as a surrogate for “routine” airway suctioning. Results: Airway suctioning was performed in 159 out of 302 video recordings and stimulated a vigorous cry in 47 (29.6%) infants, resulting in improvements in muscle tone (p = 0.09) and skin colour (p < 0.001). In 43 (27.0%) infants, airway suctioning preceded the initiation of PPV. Conclusions: In this single-centre observational study, airway suctioning stimulated a vigorous cry with resulting improvements in muscle tone and skin colour. Airway suctioning was often performed prior to the initiation of PPV, indicating a practice of routine suctioning and guideline non-compliance.
A retrospective analysis of prospectively collected observational data from Akershus University Hospital (AUH) from August 2014 to November 2016 was performed. AUH has a 570,000-person catchment area and 5000 annual deliveries from 26 weeks of gestation onwards. All delivery rooms were equipped with a resuscitation table with radiant heat, a pulse oximeter, an oxygen blender, a gas-driven suction device, a self-inflating bag and a T-piece resuscitator. The equipment for endotracheal intubation and intravenous access was readily available, whereas electrocardiogram (ECG) monitoring was not routinely used in the data collection period. Airway suctioning was performed with a suction catheter with a maximum negative pressure of 100 mmHg (13 kPa, 135 cm H2O), as recommended in [7,8], while visible secretions outside of the mouth and on the face were wiped off with a towel. Midwives managed all stages of labour unless a complicated birth was foreseen. In such cases, one or more obstetricians were responsible. A paediatric resident was present at deliveries prior to 36 weeks of gestation or in the case of obstructed labour or suspected asphyxia. The Norwegian neonatal intensive care units (NICUs) did not have designated resuscitation teams or respiratory therapists. In the case of an infant in unforeseen poor condition at birth or a grade I caesarean section (grade I: immediate; grade II: fast; grade III: early delivery, but no maternal or foetal compromise; and grade IV: delivery at a time to suit the woman and maternity services), a paediatric resident and a consultant neonatologist or paediatrician were paged. The paging of NICU nurses was practised as needed. All health personnel involved in neonatal resuscitation and stabilization followed the Norwegian Resuscitation Council (NRC) guidelines for neonatal resuscitation, adapted from ILCOR [9], the Australian and New Zealand Committee on Resuscitation [10] and the European Resuscitation Council [11]. The 2015 Norwegian guidelines recommend PPV with a T-piece or self-inflating bag for non-breathing or gasping newborns with a heart rate (HR) of <100 beats per minute (bpm) for 60 s before reassessing their HR. If their HR remains <100 bpm, another 30–60 s PPV should be provided before the initiation of chest compressions, which are performed if their HR is <60 bpm. Intubation was envisaged at several stages but was not mandatory before the initiation of chest compressions. It should be noted that the 2010 guidelines that were followed during parts of the data accumulation period recommended adequate PPV for ”at least 30 s” prior to considering chest compressions [4]. The NRC airway suction recommendations advise that ventilation must be started in all infants who need it without prior suctioning [12], i.e., routine suctioning is not recommended. Oro-pharyngeal suction may delay spontaneous respiration and the initiation of necessary PPV and cause laryngeal spasm, vasovagal bradycardia and oedema of the airways. Even suctioning meconium from the infant’s airways is not recommended as it does not reduce the incidence of meconium aspiration syndrome and can delay the start of PPV. Suctioning should only be performed if mucus, vernix, meconium or blood is suspected of obstructing the airway and should then be performed under visual guidance, ideally with a laryngoscope and a thick suction catheter [12]. Video cameras (VC) with audio (Hikvision 2 megapixel IP camera, Hangzhou, China) and motion-activation were installed under the resuscitation tables’ overhead warmers. VC focused on the infant and the health personnel’s hands on the infant, but not on the patient monitor or personnel present. All infants placed on the resuscitation table during the study period were video filmed and assessed for eligibility. Videos containing PPV were downloaded to a computer and reviewed. The inclusion criteria in this study incorporated all infants, regardless of their gestational age, who were brought to the resuscitation table and underwent stabilization and resuscitation actions, including PPV and airway suctioning. Non-suctioned infants who underwent PPV were included as a control group with regard to the immediate clinical outcomes. A research assistant with no practical neonatal resuscitation experience and no knowledge of the study’s research questions transcribed the videos using Interact software version 9 (Mangold Int GmbH, Arnstorf, Germany). A paediatrician (AMB) made transcripts of a random selection of 20 of the recordings. Although no inter- or intra-rater variability test was performed, these 20 transcripts were considered to be consistent with the research assistant’s transcripts of the same recordings. The transcripts contained information on airway suctioning, provision of PPV, intubation and chest compressions, spontaneous breathing, crying, muscle tone and skin colour. A vigorous infant was defined as one who breathed spontaneously, cried and had good muscle tone, the last of which was evaluated by flexed extremities and spontaneous movements. This article presents the secondary processing of some transcripts presented in [13,14,15]. The primary use of the collected data was to scrutinize the effect of “high frequency, short duration” simulations and facilitator-led debriefings where the video logs were used for reflection and learning. ALS, a consultant neonatologist and GB, analysed the transcripts quantitatively and qualitatively. Primary outcome: Effect of airway suctioning on muscle tone and skin colour. Secondary outcome: The fraction of airway suctioning before the initiation of PPV as a surrogate for “routine” airway suctioning, i.e., guideline non-compliance. Statistical analyses were performed in SPSS v28 (SPSS Inc., Chicago, IL, USA). Continuous data are presented as numbers with percentages or medians with interquartile ranges (IQR). Muscle tone and skin colour were scored 0–2, as in the Apgar score [16], immediately before and immediately after a suction episode. The McNemar test was used to analyse differences in the proportion of scores 0, 1 and 2 before and after airway suctioning. A p-value of < 0.05 was considered significant. Analyses were performed for the entire cohort, as well as for premature (gestational age (GA) ≤ 32 + 6 weeks) and late preterm/term (GA ≥ 33 + 0 weeks) infants born through clear and meconium-stained amniotic fluid. A cohort of non-suctioned infants receiving PPV was used as control. A comparison of the subgroups was performed with a Mann–Whitney U test for continuous variables and a Chi-Square test for categorical variables. The Regional Committee for Medical and Health Research Ethics South East approved the project. Video recording and evaluation were considered quality assurance and associated with minimal risk. Thus, the institutional review board at AUH approved presumed consent from the parents (reference 14-032). A written notification, including a withdrawal form for the study, was given to all women planning to give birth at AUH. The parents could bring the withdrawal form to the hospital as a way to opt out. They could also withdraw verbally and have the video deleted. A description of the study was found on a publicly available webpage. All health personnel were notified of the study and could refuse participation and have video recordings deleted without review. Due to confidentiality requirements, health personnel’s ages, experiences and training were not collected. The institutional review board’s approval and acceptance were dependent on the deletion of all videos after scrutiny and transcription.
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