New Strategies of Pulmonary Protection of Preterm Infants in the Delivery Room with the Respiratory Function Monitoring

Abstract

Objective To investigate if the use of a visible respiratory function monitor (RFM) to use lower tidal volumes (Vts) during positive pressure ventilation (PPV) in the delivery room (DR) reduces the need of surfactant administration and invasive mechanical ventilation during the first 72 hours after birth of preterm infants <32 weeks' gestational age (GA).

Study Design Infants <32 weeks' GA (n = 106) requiring noninvasive PPV were monitored with a RFM at birth and randomized to visible (n = 54) or masked (n = 52) display on RFM. Pulmonary data were recorded during the first 10 minutes after birth. Secondary analysis stratified patients by GA (<28, 28–29⁺⁶, or ≥30 weeks).

Results Median expiratory Vts during inflations were greater in the masked group (7 mL/kg) than in the visible group (5.8 mL/kg; p = 0.001) same as peak inflation pressure (PIP) administered (21.5 vs. 19.7 cmH₂O; p < 0.001). Consequently, minute volumes were greater in the masked group (256 vs. 214 mL/kg/min; p < 0.001), with no differences in respiratory rate. These differences were higher in those <30 weeks' GA. There was no difference in the need of surfactant administration or intubation during the first 72 hours of age.

Conclusion Using a RFM in the DR prevents the use of large Vt and PIP during respiratory support inflations, mostly in the more immature newborn infants, but with no other short-term benefits.

Keywords

tidal volume - respiratory function monitor - stabilization - ventilation - preterm infant

Ethical Approval

The Gregorio Marañón University Hospital Research and Ethics Committees provided Ethics approval.

• References

• 1 Wiswell TE. Resuscitation in the delivery room: lung protection from the first breath. Respir Care 2011; 56 (09) 1360-1367
• 2 O'Donnell CPF, Schmölzer GM. Resuscitation of preterm infants: delivery room interventions and their effect on outcomes. Clin Perinatol 2012; 39 (04) 857-869
• 3 Perlman JM, Wyllie J, Kattwinkel J. , et al; Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics 2015; 136 (Suppl. 02) S120-S166
• 4 Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation 2015; 95: 249-263
• 5 Schmölzer GM, Kamlin OC, O'Donnell CP, Dawson JA, Morley CJ, Davis PG. Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2010; 95 (06) F393-F397
• 6 Poulton DA, Schmölzer GM, Morley CJ, Davis PG. Assessment of chest rise during mask ventilation of preterm infants in the delivery room. Resuscitation 2011; 82 (02) 175-179
• 7 Björklund LJ, Ingimarsson J, Curstedt T. , et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr Res 1997; 42 (03) 348-355
• 8 Hillman NH, Moss TJ, Kallapur SG. , et al. Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep. Am J Respir Crit Care Med 2007; 176 (06) 575-581
• 9 te Pas AB, Wong C, Kamlin CO, Dawson JA, Morley CJ, Davis PG. Breathing patterns in preterm and term infants immediately after birth. Pediatr Res 2009; 65 (03) 352-356
• 10 Schmölzer GM, Morley CJ, Wong C. , et al. Respiratory function monitor guidance of mask ventilation in the delivery room: a feasibility study. J Pediatr 2012; 160 (03) 377-381
• 11 Kattwinkel J, Stewart C, Walsh B, Gurka M, Paget-Brown A. Responding to compliance changes in a lung model during manual ventilation: perhaps volume, rather than pressure, should be displayed. Pediatrics 2009; 123 (03) e465-e470
• 12 Schmölzer GM, Kamlin OC, Dawson JA, te Pas AB, Morley CJ, Davis PG. Respiratory monitoring of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 2010; 95 (04) F295-F303
• 13 Schmölzer GM, Dawson JA, Kamlin CO, O'Donnell CPF, Morley CJ, Davis PG. Airway obstruction and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2011; 96 (04) F254-F257
• 14 Kaufman J, Schmölzer GM, Kamlin CO, Davis PG. Mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2013; 98 (05) F405-F410
• 15 Mian QN, Pichler G, Binder C. , et al. Tidal volumes in spontaneously breathing preterm infants supported with continuous positive airway pressure. J Pediatr 2014; 165 (04) 702-706
• 16 Mian Q, Cheung P-Y, O'Reilly M. , et al. Spontaneously breathing preterm infants change in tidal volume to improve lung aeration immediately after birth. J Pediatr 2015; 167 (02) 274-278
• 17 Dawson JA, Kamlin CO, Vento M. , et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 2010; 125 (06) e1340-e1347
• 18 Iriondo M, Szyld E, Vento M. , et al. Adaptación de las recomendaciones internacionales sobre reanimación neonatal 2010: comentarios. Pediatria (Napoli) 2011; 75 (03) 203.e1-203.e14
• 19 Zeballos Sarrato G, Salguero García E, Aguayo Maldonado J, Gómez Robles C, Thió Lluch M, Iriondo Sanz M. ; Grupo de Reanimación Neonatal de la Sociedad Española de Neonatología (GRN-SENeo). [Changes in the international recommendations on neonatal stabilisation and resuscitation (2015)]. An Pediatr (Barc) 2017; 86 (01) 51.e1-51.e9
• 20 O'Donnell CPF, Kamlin CO, Davis PG, Morley CJ. Neonatal resuscitation 1: a model to measure inspired and expired tidal volumes and assess leakage at the face mask. Arch Dis Child Fetal Neonatal Ed 2005; 90 (05) F388-F391
• 21 Turner MJ, MacLeod IM, Rothberg AD. Effects of temperature and composition on the viscosity of respiratory gases. J Appl Physiol (1985) 1989; 67 (01) 472-477
• 22 Barton SK, Tolcos M, Miller SL. , et al. Ventilation-induced brain injury in preterm neonates: a review of potential therapies. Neonatology 2016; 110 (02) 155-162
• 23 Barton SK, Tolcos M, Miller SL. , et al. Unraveling the links between the initiation of ventilation and brain injury in preterm infants. Front Pediatr 2015; 3: 97
• 24 ILCOR CoSTR Web site. Conversations · Disqus. Disqus. Available at: https://disqus.com/home/forum/ahapico/ . Accessed February 1, 2016
• 25 Schmölzer GM, Te Pas AB, Davis PG, Morley CJ. Reducing lung injury during neonatal resuscitation of preterm infants. J Pediatr 2008; 153 (06) 741-745
• 26 Björklund LJ, Ingimarsson J, Curstedt T, Larsson A, Robertson B, Werner O. Lung recruitment at birth does not improve lung function in immature lambs receiving surfactant. Acta Anaesthesiol Scand 2001; 45 (08) 986-993
• 27 Leone TA, Finer NN, Rich W. Delivery room respiratory management of the term and preterm infant. Clin Perinatol 2012; 39 (03) 431-440
• 28 Murthy V, D'Costa W, Shah R. , et al. Prematurely born infants' response to resuscitation via an endotracheal tube or a face mask. Early Hum Dev 2015; 91 (03) 235-238
• 29 van Vonderen JJ, van Zanten HA, Schilleman K. , et al. Cardiorespiratory monitoring during neonatal resuscitation for direct feedback and audit. Front Pediatr 2016; 4: 38
• 30 Kang LJ, Cheung P-Y, Pichler G, O'Reilly M, Aziz K, Schmölzer GM. Monitoring lung aeration during respiratory support in preterm infants at birth. PLoS One 2014; 9 (07) e102729
• 31 Harris C, Bhat P, Murthy V, Milner AD, Greenough A. The first breath during resuscitation of prematurely born infants. Early Hum Dev 2016; 100: 7-10
• 32 Tracy M, Downe L, Holberton J. How safe is intermittent positive pressure ventilation in preterm babies ventilated from delivery to newborn intensive care unit?. Arch Dis Child Fetal Neonatal Ed 2004; 89 (01) F84-F87
• 33 Polglase GR, Miller SL, Barton SK. , et al. Initiation of resuscitation with high tidal volumes causes cerebral hemodynamic disturbance, brain inflammation and injury in preterm lambs. PLoS One 2012; 7 (06) e39535
• 34 Vento M, Aguar M, Leone TA. , et al. Using intensive care technology in the delivery room: a new concept for the resuscitation of extremely preterm neonates. Pediatrics 2008; 122 (05) 1113-1116
• 35 Murthy V, Creagh N, Peacock JL. , et al. Inflation times during resuscitation of preterm infants. Eur J Pediatr 2012; 171 (05) 843-846