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Outcomes for PEEP versus no PEEP in the delivery room

Question Type:
Intervention
Full Question:
In preterm/term newborn infants who do not establish respiration at birth (P), does does the use of PEEP as part of the initial ventilation strategy (I), compared with as compared with no PEEP improve (C), change survival to discharge, 5-minute APGAR scores, time for heart rate to rise above 100 beats per minute, intubation rate in the delivery room, chest compressions in the delivery room, heart rate, incidence of air leaks, oxygen saturation/oxygenation, FiO2 exposure in the delivery room, mechanical ventilation in the first 72 hours, BPD (O)?
Consensus on Science:
For the critical outcome of mortality before discharge, we identified low-quality evidence from 2 randomized trials of 596 preterm newborns showing no benefit (RR, 0.616; 95% CI, 0.274–1.382) to providing PEEP compared with no PEEP (downgraded for serious imprecision and risk of bias). (Dawson 2011, 912; Szyld 2014, 234) For the critical outcome of chronic lung disease, we identified moderate-quality evidence from 2 randomized trials of 596 preterm newborns showing no benefit (RR, 1.153; 95% CI, 0.711–1.871) to providing PEEP as compared with no PEEP (downgraded for imprecision and risk of bias). (Dawson 2011, 912; Szyld 2014, 234) For the critical outcome of need for cardiac drugs or chest compressions in the delivery room, we identified low-quality evidence from 2 randomized trials of 596 preterm newborns showing no benefit (RR, 1.468; 95% CI, 0.550–3.917) to providing PEEP as compared with no PEEP (Dawson 2011, 912; Szyld 2014, 234) (downgraded for imprecision and risk of bias). For the important outcome of oxygen saturation at 5 minutes after birth, we identified moderate-quality evidence from 1 randomized trial of 80 preterm newborns showing no benefit (P=0.55) to providing PEEP (median SpO2, 49%; interquartile range [IQR], 25%–90%) versus not providing PEEP (median SpO2, 59%; IQR, 33%–66%) (downgraded for imprecision and risk of bias).(Dawson 2011, 912) For the important outcome of maximum concentration of oxygen used during resuscitation, we identified low-quality evidence from 1 randomized trial of 516 preterm newborns showing moderate benefit (P=0.005) to providing PEEP (mean, 48%; standard deviation [SD], 0.2) versus not providing PEEP (mean, 53%; SD, 0.2).(Szyld 2014, 234) For the important outcome of heart rate greater than 100/min at 2 minutes of age, we identified low-quality evidence from 1 randomized trial of 516 preterm newborns showing no benefit to providing PEEP versus not providing PEEP (RR, 1.656; 95% CI, 0.938–2.923) (downgraded for imprecision and risk of bias).(Szyld 2014, 234) For the important outcome of time for heart rate to rise to greater than 100/min, we identified moderate-quality evidence from 1 randomized trial of 516 preterm newborns showing no benefit to providing PEEP (median, 1 minute; IQR, 0.5–1.8) versus not providing PEEP (median, 1 minute; IQR, 0.5–1.9) (downgraded for imprecision and risk of bias). (Szyld 2014, 234) For the important outcome of need for intubation in the delivery room, we identified moderate-quality evidence from 2 randomized trials of 596 preterm newborns showing no benefit (RR, 1.208; 95% CI, 0.907–1.609) to providing PEEP (downgraded for imprecision and risk of bias) (Dawson 2011, 912; Szyld 2014, 234) versus not providing PEEP. For the important outcome of need for mechanical ventilation in the first 72 hours, we identified low-quality evidence from 1 randomized trial of 80 preterm newborns showing no benefit (RR, 0.317; 95% CI, 0.093–1.086) to providing PEEP (downgraded for imprecision and risk of bias) versus not providing PEEP. We identified only 1 randomized clinical trial that included term infants, (Szyld 2014, 234) which provided insufficient data to address this question as a secondary outcome measure in a subgroup analysis (very-low-quality evidence, downgraded for serious imprecision and risk of bias). For the important outcome of pulmonary air leaks, we identified low-quality evidence from 2 randomized trials of 596 preterm newborns showing no benefit (RR, 1.401; 95% CI, 0.414–4.735) to providing PEEP (downgraded for imprecision and risk of bias) (Dawson 2011, 912; Szyld 2014, 234) versus not providing PEEP. For the important outcome of Apgar score less than 6 at 5 minutes, we identified moderate-quality evidence from 1 randomized trial of 516 preterm newborns showing no benefit to providing PEEP (RR, 0.813; 95% CI, 0.472–1.402) (downgraded for imprecision and risk of bias) (Szyld 2014, 234) versus not providing PEEP. For the less-important outcome of Apgar score at 5 minutes, we identified moderate-quality evidence from 1 randomized trial of 80 preterm newborns showing no benefit (P=0.18) to providing PEEP (median, 7; IQR, 6–8) versus no PEEP (median, 7; IQR, 6–9) (downgraded for imprecision and risk of bias).(Dawson 2011, 912)
Treatment Recommendation:
We suggest using PEEP ventilation for premature newborns during delivery room resuscitation (weak recommendation, low-quality evidence). We cannot make any recommendation for term infants because of insufficient data. Values, Preferences, and Task Force Insights In making this suggestion, we are considering the small reduction in maximum oxygen concentration needed during resuscitation with 5 cm H2O PEEP compared with those not receiving PEEP shown in 1 human study, and considering the evidence from animal studies (see NRP 809). Interpretation of human studies is further complicated by varying interfaces (eg, face mask versus endotracheal tube) and methods of generating PEEP (eg, self-inflating bags with PEEP valve versus T-piece resuscitator). Only 1 study was available to indirectly address the specific PICO question,(Szyld 2014, 234) where a subgroup comparison was applied. Good animal studies are available but are classified as low levels of evidence from the point of applicability due to indirectness (see NRP 809). There was concern that the evidence based on the GRADE criteria was regarded as low quality. There was a major struggle to come up with a recommendation when the evidence was weak. The only positive effect found was a 5% change in FIO2 (see comments after NRP 870).

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