Fixed pressure devices (T-pieces) or hand driven pressure devices (BAGS) for resuscitation at birth: a systematic review and meta-analysis

Background: Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are commonly available: fixed pressure devices (FP; T-pieces or ventilators) and hand driven pressure devices (HDP; eg self-inflating bags). There is no consensus about benefices that each option offers. However, some studies reported a higher incidence of pneumothorax since T-piece utilisation.

Methods: A systematic review and meta-analysis was carried out. Medline, Embase, Scopus and Cochrane Library of Trials were searched. Randomised, quasi-randomised studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included.

Results: Eight (8) studies recruiting 3571 newborns were included: 4 RCTs, 2 qRCTs and 2 prospective cohorts. Mortality was decreased in FP group (OR 0.57 95% CI (0.47–0.69)−NNT 12.5). Several respiratory outcomes were also improved: intubation in the delivery room (OR 0.55 (0.39–0.79)−NNT 7), mechanical ventilation (OR 0.58 (0.42–0.80)−NNT 7) and its duration (SMD −0.16 (−0.29 to −0.03)), surfactant administration in premature infants (OR 0.67 (0.55–0.82)−NNT 30) and combined risk of mortality or bronchopulmonary dysplasia (RR 0.60 (0.50–0.71)−NNT 9). Decreases in mortality, intubation and mechanical ventilation rates remained when focusing on randomized studies (RR 0.62 (0.41–0.94), RR 0.61 (0.38–0.99) and RR 0.72 (0.53–0.98)) respectively). Common morbidities of premature birth as patent ductus requiring treatment, intraventricular haemorrhage, retinopathy of premature and necrotizing enterocolitis were similar in the two groups. The risk of cystic periventricular leukomalacia decreased significantly with FP (OR 0.59 (0.41–0.85)−NNT 27). Finally, there wasn’t any significant difference in pneumothorax rates between the two groups (OR 0.82 (0.44–1.52)).

Conclusion: Resuscitation at birth with fixed pressure devices increases its effectiveness, without increasing morbidity. Longer term benefits may include decreased mortality, mortality or bronchopulmonary dysplasia, and cystic periventricular leukomalacia.
Devices providing fixed pressures should therefore prevail for resuscitation at birth.
Registration: PROSPERO 2020 CRD42020191685