Endotracheal-Suctioning Curb Tied to Respiratory Problems in Some Newborns

By David Douglas

November 06, 2018

NEW YORK (Reuters Health) - Avoidance of routine endotracheal suctioning of meconium-stained nonvigorous newborns, as recommended in recent guidelines, may be associated with a higher risk of respiratory problems, according to Texas-based researchers.

Previously, nonvigorous newborns born through meconium-stained amniotic fluid (MSAF) "were routinely intubated and suctioned below the vocal cords to prevent perinatal aspiration of meconium," Dr. Arpitha Chiruvolu of Baylor University Medical Center, in Dallas, and colleagues note in Pediatrics, online November 1. Guidelines from the Neonatal Resuscitation Program now suggest that positive-pressure ventilation should be used instead, the team adds.

To investigate, the team examined data on 130 nonvigorous neonates born a year before implementation of the new guidelines and on 101 infants born in the year after they went into effect. Maternal and other characteristics were similar between these groups.

Endotracheal suctioning was performed in 70% of the pre-implementation group compared to only 2% of those born after the change in management. However, significantly more infants in the post-implementation group were admitted to the neonatal intensive care unit (NICU) than had been the case before the change (40% vs. 22%; odds ratio, 2.2)

There were similar findings for need of oxygen therapy (37% vs. 19%; OR, 2.5), mechanical ventilation (19% vs. 9%; OR, 2.6) and surfactant therapy (10% vs. 2%; OR, 5.8). There were no differences in the incidences of other outcomes, including meconium-aspiration syndrome and hypoxic-ischemic encephalopathy.

Given these findings and the fact that the new recommendations were "not based on large randomized controlled trials performed in the developed world," the researchers call for such trials "to look into the safety and efficacy of this practice change."

Dr. Marie Blomberg, a professor in the division of children's and women's health at Linkoping University, in Sweden, likened the choice to that between plague and cholera.

"This change in clinical practice, avoiding a large number of intubations, did not increase the number of infants with the severe complication of meconium aspiration syndrome," she told Reuters Health by email. "On the other hand, the authors found a higher proportion of newborns admitted to the NICU for respiratory issues, more infants who needed oxygen therapy and mechanical ventilation, in the group treated with positive-pressure ventilation."

"This study," she concluded, "elucidates the ongoing challenge in clinical care, to figure out what risks are in a sense acceptable to take and which are not."

Dr. Srinivas Murki, head of the NICU at Fernandez Hospital, in Hyderabad, India, questioned the new results and suggested that "Lack of uniformity in definitions for need of surfactant, need for oxygen and ventilation and differences in patient population in the two arms of the study may be reasons for the observed differences in outcomes as reported by the authors."

Dr. Murki, who does research in the field, added that in two randomized controlled trials in India, "non-suctioning of the endotracheal tube did not result in increased incidence of the morbidities as reported in this (study). The proportions of infants were similar in both the study and control groups for late preterm and fetal distress in both the trials. The proportions of infants with meconium-aspiration syndrome, mechanical ventilation, and duration of oxygen therapy were similar between the groups."

Dr. Chiruvolu did not respond to requests for comments.

SOURCE: https://bit.ly/2RBqabN

Pediatrics 2018.