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Nebulized racemic epinephrine for extubation of newborn infants

  • Review
  • Intervention

Authors

  • Mark W Davies,

    Corresponding author
    1. Department of Paediatrics & Child Health, The University of Queensland, Grantley Stable Neonatal Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
    • Mark W Davies, Grantley Stable Neonatal Unit, Royal Brisbane and Women's Hospital, Department of Paediatrics & Child Health, The University of Queensland, Butterfield St, Herston, Brisbane, Queensland, 4029, Australia. Mark_Davies@health.qld.gov.au.

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  • Peter G Davis

    1. The Royal Women's Hospital, Department of Newborn Research, Parkville, Victoria, Australia
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Abstract

Background

Following a period of mechanical ventilation, post-extubation upper airway obstruction can occur in newborn infants, especially after prolonged, traumatic or multiple intubations. The subsequent increase in upper airway resistance may lead to respiratory insufficiency and failure of extubation. The vasoconstrictive properties of epinephrine, and its proven efficacy in the treatment of croup in infants, has led to the routine use of inhaled nebulized epinephrine immediately post-extubation in some neonatal units. It is also recommended for neonates with post-extubation tracheal obstruction and stridor in neonatal and respiratory textbooks and reviews.

Objectives

The primary objective was to assess whether nebulized epinephrine administered immediately after extubation in neonates weaned from IPPV decreases the need for subsequent additional respiratory support.

Search methods

Searches were of: MEDLINE from 1966 to September 2000; CINAHL from 1982 to September 2000; Current Contents from 1994 to September 2000; and the Cochrane Controlled Trials Register (Cochrane Library Issue 3, 2000). These searches were updated to September 2001 for this review update. Previous searches up to March 1999 included the Oxford Database of Perinatal Trials, expert informants and journal hand searching mainly in the English language, previous reviews including cross references, abstracts, and conference and symposia proceedings.
This search was updated in December 2009.

Selection criteria

All randomised and quasi-randomised control trials in which nebulized epinephrine was compared with placebo immediately post-extubation in newborn infants who have been weaned from IPPV and extubated, with regard to clinically important outcomes (i.e. need for additional respiratory support, increase in oxygen requirement, respiratory distress, stridor or the occurrence of side effects).

Data collection and analysis

No studies met our criteria for inclusion in this review.

Main results

No studies were identified which looked at the effect of inhaled nebulized epinephrine on clinically important outcomes in infants being extubated.

Authors' conclusions

Implications for practice: There is no evidence either supporting or refuting the use of inhaled nebulized racemic epinephrine in newborn infants.

Implications for research: randomised controlled trials are needed comparing inhaled nebulized racemic epinephrine with placebo in neonates post-extubation. This should be looked at both as a routine treatment post-extubation and as specific treatment for post-extubation upper airway obstruction. Study populations should include the group of infants at highest risk for upper airway obstruction from mucosal swelling because of their small glottic and subglottic diameters (i.e. those infants with birth weights less than 1000 grams).

摘要

背景

噴霧性葡萄酸化合物腎上腺素用於新生兒拔管

在使用一段時間機械式呼吸後,新生兒可能發生拔管後上呼吸道阻塞,特別是插管時間過長、發生創傷或是多次插管,隨後發生上呼吸道阻力增加導致呼吸功能不全和拔管失敗。腎上腺素的血管收縮特性以及用於嬰兒哮吼的功效,使有些新生兒單位將拔管後立即吸入噴霧性腎上腺素視為常規治療,並且在新生兒或呼吸相關的教科書和回顧性文章中,也被建議使用在新生兒拔管後發生氣管阻塞及喘鳴時。

目標

主要的目的是要瞭解噴霧性腎上腺素立即使用在新生兒拔管並脫離間歇式正壓呼吸器後,能否減少額外呼吸支持的需求?

搜尋策略

搜尋MEDLINE從1996年到2000年9月、CINAHL從1982年到2000年9月、Current Contents從1994年到2000年9月以及Cochrane Controlled Trials Register (Cochrane Library Issue 3, 2000) 。並為了更新這篇回顧文章,這些搜尋更新到2001年9月,先前的搜尋到1999年3月為止包括Oxford Database of Perinatal Trials、專業資料以及手動搜尋以英文為主的期刊,先前的回顧性文章包括交互參考資料、摘要及會議和研討會記錄。

選擇標準

所有隨機及半隨機對照試驗,比較新生兒拔管並脫離間歇式正壓呼吸器後立即使用噴霧性腎上腺素與安慰劑,有關的重要臨床結果(如:需要額外呼吸支持、增加氧氣需求、呼吸窘迫、喘鳴或副作用發生)。

資料收集與分析

沒有任何研究符合我們這篇回顧性文章的納入標準。

主要結論

沒有研究探討吸入噴霧性腎上腺素用於嬰兒拔管後對臨床結果的影響。

作者結論

實行的涵義:沒有證據支持或反駁新生兒使用吸入噴霧性葡萄酸化合物腎上腺素。研究的涵義:需要隨機對照試驗來比較吸入噴霧性腎上腺素和安慰劑用於新生兒拔管後,必須同時著眼於拔管後常規治療及拔管後發生上呼吸道阻塞的特殊治療。研究族群需包括因聲門及聲門下直徑較小而黏膜腫脹發生上呼吸道阻塞的高危險嬰兒(例如出生體重小於1000公克的嬰兒)。

翻譯人

本摘要由馬偕醫院王臻誼翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

沒有任何隨機對照試驗證據支持或反駁新生兒拔管後使用吸入噴霧性腎上腺素。使用機械式呼吸後,新生兒可能發生上呼吸道腫脹和阻塞(特別是在插管過久、發生創傷或是多次插管),可能損害呼吸並導致拔管失敗;因為腎上腺素可減少腫脹,以及被證實可用於治療嬰兒哮吼,因此在拔管後被立即給予用來預防呼吸問題。檢閱者並沒有發現任何研究測試出新生兒使用入噴霧性腎上腺素後,臨床上有意義的結果,他們因而認為沒有任何證據支持或反駁新生兒使用吸入噴霧性腎上腺素。

Plain language summary

Nebulized racemic epinephrine for extubation of newborn infants

The use of inhaled nebulized epinephrine after extubation in newborn infants is not supported or refuted by evidence from randomised controlled trials. Following mechanical ventilation, airway swelling and obstruction can occur in newborn infants (especially after prolonged, traumatic or multiple intubations). This may compromise breathing and cause failure of extubation. Because epinephrine can decrease swelling and its effect has been proven in the treatment of croup in infants, it has been used immediately after extubation to prevent breathing problems. The reviewers did not identify any studies that examined clinically relevant outcomes following the use of nebulized epinephrine in newborn infants. They concluded that there is no evidence either supporting or refuting the use of inhaled nebulized epinephrine in newborn infants.

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