What are the guidelines for using an orogastric (OG) tube and positive end-expiratory pressure (PEEP) in newborn care?

From the Guidelines

The use of an orogastric (OG) tube and positive end-expiratory pressure (PEEP) in newborn care should be guided by the most recent and highest quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life. When considering the use of OG tubes and PEEP in newborn care, it is essential to prioritize the most recent and highest quality evidence. According to the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1, the use of PEEP during delivery room resuscitation of preterm newborns resulted in no significant improvement in mortality, need for cardiac drugs or chest compressions, or rapid improvement in heart rate. However, the guidelines suggest using approximately 5 cm H2O PEEP when administering positive pressure ventilation (PPV) to preterm newborns (Class IIb, LOE B-R).

Key Considerations for OG Tube and PEEP Use

• OG tubes should be inserted using proper measurement techniques to determine appropriate insertion depth, and their position should be verified by aspirating gastric contents and checking pH or through radiographic confirmation when necessary.
• PEEP initial settings typically range from 4-6 cmH2O for most neonates requiring respiratory support, with adjustments based on oxygenation status, work of breathing, and lung compliance.
• Higher PEEP levels (7-10 cmH2O) may be needed for preterm infants with respiratory distress syndrome or poor lung compliance.
• Continuous monitoring of vital signs, oxygen saturation, and blood gases is essential when using PEEP to prevent complications such as pneumothorax or decreased cardiac output.

Physiological Basis for PEEP

The physiological basis for PEEP is that it prevents alveolar collapse at end-expiration, improves functional residual capacity, and enhances gas exchange, particularly important in premature infants whose lungs lack adequate surfactant. As noted in the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1, the use of PEEP during initial stabilization after birth improved functional residual capacity, oxygenation, and lung compliance and reduced lung injury in intubated immature animals. However, high levels of PEEP (8 to 12 cm H2O) may reduce pulmonary blood flow and increase the risk of pneumothorax.

Recommendation

The use of approximately 5 cm H2O PEEP is suggested when administering PPV to preterm newborns, as recommended by the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1. This recommendation prioritizes the most recent and highest quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life in newborn care.

From the Research

Guidelines for OG Tube Placement

• The correct placement of an orogastric (OG) tube is crucial in newborn care, as an abnormally placed tube can indicate underlying serious conditions, such as esophageal perforation or gastrointestinal anomalies 2.
• Feeding tube position is not only important for feeding practice but also has diagnostic implications in newborn infants 2.
• There are different types of feeding tubes that can be used in children, including nasogastric (NG), orogastric, gastrostomy (G), and gastrojejunostomy (GJ) tubes 3.

Guidelines for PEEP in Newborn Care

• Positive end-expiratory pressure (PEEP) is a critical component of mechanical ventilation in newborn care, as it helps to prevent alveolar collapse and improve oxygenation 4, 5.
• High-frequency oscillatory ventilation (HFOV) is a lung-protective strategy that can be used in newborn care, which combines low tidal volumes with high continuous distending pressure (CDP) and is generated using high fresh gas flows 4, 5.
• HFOV can be regarded as an ultimate form of lung-protective ventilatory strategy, aiming to minimize the risk of ventilator-associated lung injury (VALI) 4.

Clinical Applications

• HFOV is often utilized as a rescue strategy when conventional mechanical ventilation (CV) has failed, and is particularly useful in patients with acute respiratory distress syndrome (ARDS) 5, 6.
• The use of HFOV requires careful patient selection, monitoring, and adjustment of ventilatory parameters to optimize oxygenation and ventilation 5, 6.
• Adjunctive therapies, such as neuromuscular blockade, recruitment maneuvers, and nitric oxide, may be used in conjunction with HFOV to improve outcomes 6.