Published online November 1, 2007
PEDIATRICS Vol. 120 No. 5 November 2007, pp. 1222-1223 (doi:10.1542/peds.2007-2613)

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LETTER TO THE EDITOR

Possible Sequelae of Sustained Lung Inflation in Resuscitation of Preterm Infants: In Reply

Arjan B. te Pas, MD
Frans J. Walther, MD, PhD
Division of Neonatology
Department of Pediatrics
Leiden University Medical Center
2300 RC Leiden, Netherlands

We thank Dr Molloy for her interest in our randomized, controlled trial (RCT).¹ She makes several comments about prolonged inflations, but her main question is unclear.

She refers to a Cochrane review² and writes, "However, a long inspiratory time is associated with a significant increase in air leak." This review analyzed trials of ventilation that used long inspiratory times for infants with respiratory distress syndrome in the NICU. It was not about prolonged inflation during delivery room resuscitation and, therefore, is not appropriate in the context of this trial.^1,2

We are not sure why Molloy refers to a retrospective study by Lindner et al³ and our RCT and states that "small numbers may prevent statistical significance in either benefits or complications." Both studies were large enough to show significant benefit with a decreased incidence of intubations.

Molloy refers to a study by Harling et al,⁴ which showed no difference in outcome between an initial inflation of 5 versus 2 seconds at the start of resuscitation for preterm infants, but as Molloy noted correctly, that sample size was small.

We did not record changes in blood gasses, median fraction of inspired oxygen (FIO₂), or median peak pressures for the first 24 hours. Nevertheless, we did report the first blood gas in the NICU and the maximum FIO₂ with no difference between the 2 groups.¹ There was also no difference in the maximal peak pressure of ventilated infants (20.1 ± 2.4 [early functional respiratory capacity intervention (EFURCI) group] vs 19.2 ± 4.3 [conventional group] cmH₂O; P = .2).

We think Molloy misread the incidence of pneumothorax. The results (page 325, paragraph 2, lines 18–20) showed that there were fewer pneumothoraxes in the EFURCI group (1 in 104 [EFURCI] vs 7 in 103 [conventional]; P = .069).¹ There was a nonsignificant increase in severe intraventricular hemorrhage (IVH) in the EFURCI group (7 in 104 [7%] [EFURCI] vs 3 in 103 [3%] [conventional]; P = .3).¹ The incidence of severe IVH in our NICU before the trial (year 2003–2004) was 7%. In addition, in our RCT the incidence of all IVHs was significantly higher in the conventional group (14 in 104 [14%] [EFURCI] vs 28 in 103 [27%] [conventional]; P = .016). Interestingly, Lindner et al^3,5 showed no differences in IVH in either their retrospective study or RCT.

As requested, in Table 1 we show outcomes for infants <28 weeks' gestation. For comparison, we also show the incidence of complications in the 2 years before the trial. As readers will appreciate, this trial was not designed or powered to investigate this subgroup.

View this table: [in this window] [in a new window]   TABLE 1 Secondary Outcome in Infants <28 Weeks' Gestation

 

REFERENCES

1. te Pas AB, Walther FJ. A randomized, controlled trial of delivery-room respiratory management in very preterm infants. Pediatrics. 2007;120 :322 –329[Abstract/Free Full Text]
2. Kamlin CO, Davis PG. Long versus short inspiratory times in neonates receiving mechanical ventilation. Cochrane Database Syst Rev. 2004;(4):CD004503
3. Lindner W, Vossbeck S, Hummler H, Pohlandt F. Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation? Pediatrics. 1999;103 :961 –967[Abstract/Free Full Text]
4. Harling AE, Beresford MW, Vince GS, Bates M, Yoxall CW. Does sustained lung inflation at resuscitation reduce lung injury in the preterm infant? Arch Dis Child Fetal Neonatal Ed. 2005;90 :F406 –F410[Abstract/Free Full Text]
5. Lindner W, Hogel J, Pohlandt F. Sustained pressure-controlled inflation or intermittent mandatory ventilation in preterm infants in the delivery room? A randomized, controlled trial on initial respiratory support via nasopharyngeal tube. Acta Paediatr. 2005;94 :303 –309[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by te Pas, A. B. Articles by Walther, F. J. Search for Related Content PubMed Articles by te Pas, A. B. Articles by Walther, F. J. Related Collections Premature & Newborn Social Bookmarking                         What's this?