A Randomized, Controlled Trial of Delivery-Room Respiratory Management in Very Preterm Infants

Pas, Arjan B. te; Walther, Frans J.

doi:10.1542/peds.2007-0114

Cited by 233 publications

(172 citation statements)

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“…In our previous trial comparing 2 DR strategies, 21 the interface (nasal tube versus mask) was only one of several differences (T-piece, self-inflating bag, and 1 group receiving an SI) between the 2 strategies.…”

Section: Discussionmentioning

confidence: 99%

“…[14][15][16][17][18] The use of a nasal interface in the DR has been studied but in more mature infants 19 using long (sustained) inflation times, 16,20 anatomic face masks as a comparator, 19 and different strategies and manual ventilation devices. 21 A study comparing a nasal interface with a round silicone face mask in the resuscitation of very immature infants, those most at risk of acquired lung injury, has not been performed.…”

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Mask Versus Nasal Tube for Stabilization of Preterm Infants at Birth: A Randomized Controlled Trial

et al. 2013

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OBJECTIVE: Positive-pressure ventilation (PPV) using a manual ventilation device and a face mask is recommended for compromised newborn infants in the delivery room (DR). Mask ventilation is associated with airway obstruction and leak. A nasal tube is an alternative interface, but its safety and efficacy have not been tested in extremely preterm infants. METHODS: An unblinded randomized controlled trial was conducted in Australia, and the Netherlands. Infants were stratified by gestational age (24–25/26–29 weeks) and center. Immediately before birth infants were randomly assigned to receive PPV and/or continuous positive airway pressure with either a nasal tube or a size 00 soft, round silicone mask. Resuscitation protocols were standardized; respiratory support was provided using a T-piece device commencing in room air. Criteria for intubation included need for cardiac compressions, apnea, continuous positive airway pressure >7 cm H2O, and fraction of inspired oxygen >0.4. Primary outcome was endotracheal intubation in the first 24 hours from birth. RESULTS: Three hundred sixty-three infants were randomly assigned; the study terminated early on the grounds of futility. Baseline variables were similar between groups. Intubation rates in the first 24 hours were 54% and 55% in the nasal tube and face mask groups, respectively (odds ratio: 0.97; 95% confidence interval: 0.63–1.50). There were no important differences in any of the secondary outcomes within the whole cohort or between the 2 gestational age subgroups. CONCLUSIONS: In infants at <30 weeks’ gestation receiving PPV in the DR, there were no differences in short-term outcomes using the nasal tube compared with the face mask.

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Section: Discussionmentioning

confidence: 99%

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Mask Versus Nasal Tube for Stabilization of Preterm Infants at Birth: A Randomized Controlled Trial

et al. 2013

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“…Recently, te Pas et al 46 reported results from a randomized, controlled trial of sustained inflation in the delivery room respiratory management of VLBW infants. These authors compared sustained inflation for 10 s at 20 cm H 2 O applied via a nasopharyngeal tube followed by NCPAP vs manual inflations with a self-inflating bag and mask followed by NCPAP in 207 preterm infants.…”

Section: Noninvasive Ventilation Strategiesmentioning

confidence: 99%

Lung protective ventilatory strategies in very low birth weight infants

Ramanathan

Sardesai

2008

J Perinatol

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Respiratory distress syndrome (RDS) is the most common respiratory diagnosis in preterm infants. Surfactant therapy and mechanical ventilation using conventional or high-frequency ventilation have been the standard of care in the management of RDS. Bronchopulmonary dysplasia (BPD) continues to remain as a major morbidity in very low birth weight infants despite these treatments. There is no significant difference in pulmonary outcome when an optimal lung volume strategy is used with conventional or high-frequency ventilation. Lung injury is directly related to the duration of invasive ventilation via the endotracheal tube. Studies using noninvasive ventilation, such as nasal continuous positive airway pressure and noninvasive positive pressure ventilation, have shown to decrease postextubation failures as well as a trend toward reduced risk of BPD. Lung protective ventilatory strategy may involve noninvasive ventilation as a primary therapy or following surfactant administration in very preterm infants with RDS. Initial steps in the management of preterm infants may also include sustained inflation to establish functional residual capacity, followed by noninvasive ventilation to minimize lung injury and subsequent development of BPD.

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“…Preclinical experimental studies of SI have been mixed (5,6,(9)(10)(11)20), with an increase in lung injury reported in some studies (21)(22)(23). Improved short-term respiratory outcomes have been reported in some clinical trials (24,25), although without long-term benefits, and an increased risk of patent ductus arteriosus (19).…”

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“…The role of recruitment maneuvers on subsequent respiratory therapies may also be important. Clinical studies of SI have suggested a reduced need for surfactant replacement following a SI (24)(25)(26). However, in preterm lambs, pretreatment with surfactant improves the lung injury patterns and response to a SI compared with post-SI surfactant (12), suggesting a recruitment maneuver may also influence subsequent respiratory therapies (8).…”

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The interrelationship of recruitment maneuver at birth, antenatal steroids, and exogenous surfactant on compliance and oxygenation in preterm lambs

et al. 2016

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Background:To describe the interrelationship between antenatal steroids, exogenous surfactant, and two approaches to lung recruitment at birth on oxygenation and respiratory system compliance (C dyn ) in preterm lambs. Methods: Lambs (n = 63; gestational age 127 ± 1 d) received either surfactant at 10-min life (Surfactant), antenatal corticosteroids (Steroid), or neither (Control). Within each epoch lambs were randomly assigned to a 30-s 40 cmH 2 O sustained inflation (SI) or an initial stepwise positive end-expiratory pressure (PEEP) open lung ventilation (OLV) maneuver at birth. All lambs then received the same management for 60-min with alveolar-arterial oxygen difference (AaDO 2 ) and C dyn measured at regular time points. results: Overall, the OLV strategy improved C dyn and AaDO 2 (all epochs except Surfactant) compared to SI (all P < 0.05; twoway ANOVA). Irrespective of strategy, C dyn was better in the Steroid group in the first 10 min (all P < 0.05). Thereafter, C dyn was similar to Steroid epoch in the OLV + Surfactant, but not SI + Surfactant group. OLV influenced the effect of steroid and surfactant (P = 0.005) on AaDO 2 more than SI (P = 0.235). conclusions: The antenatal state of the lung influences the type and impact of a recruitment maneuver at birth. The effectiveness of surfactant maybe enhanced using PEEPbased time-dependent recruitment strategies rather than approaches solely aimed at initial lung liquid clearance.i t is widely agreed that the optimal support of the preterm lung involves the combination of antenatal corticosteroid exposure, exogenous surfactant therapy, and early application of lung protective respiratory support strategies (1). Together, these therapies reduce the potential of assisted ventilation to injure the developmentally immature, surfactant-deficient preterm lung. The roles of early exogenous surfactant therapy (2) and antenatal corticosteroids (3) in improving lung mechanics, functional residual capacity, and reducing respiratory support are well established. The optimal respiratory support strategies are still debated (4-7).Ideally, lung protective respiratory support should commence during transition to ex utero life (1,8). During this period, the infant must rapidly clear lung liquid, aerate the lung, establish a functional residual capacity, and commence tidal ventilation, processes influenced by the intrinsic mechanical properties of the lung as well as the applied respiratory strategy (5,6,9-13). The optimal approach in preterm infants remains unclear but broadly requires an inflating pressure to drive fetal lung fluid into the alveoli and allow lung aeration, and positive end-expiratory pressure (PEEP) to maintain aeration and prevent fluid efflux back into the airways (14-17). In preterm animals, using an initial stepwise PEEP or open lung ventilation (OLV) approach during tidal ventilation from birth improves aeration and short-term respiratory outcomes in preterm animals via utilizing hysteresis and time dependency (6,11). However, clinical trials at birth...

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A Randomized, Controlled Trial of Delivery-Room Respiratory Management in Very Preterm Infants

Cited by 233 publications

References 43 publications

Mask Versus Nasal Tube for Stabilization of Preterm Infants at Birth: A Randomized Controlled Trial

Mask Versus Nasal Tube for Stabilization of Preterm Infants at Birth: A Randomized Controlled Trial

Lung protective ventilatory strategies in very low birth weight infants

The interrelationship of recruitment maneuver at birth, antenatal steroids, and exogenous surfactant on compliance and oxygenation in preterm lambs

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