Cerebral Oxygenation in Very Low Birth Weight Infants Supported With Sustained Lung Inflations After Birth

Abstract

Sustained lung inflations (SIs) immediately after birth might decrease the need for subsequent mechanical ventilation in preterm infants. However, effects of SIs on oxygenation and hemodynamics are undetermined. Our aim was to study immediate effects of SIs on heart rate, arterial oxygen saturation, and cerebral tissue oxygen saturation in preterm infants supported with SIs after birth for lung recruitment. Heart rate, arterial oxygen saturation, and cerebral tissue oxygen saturation using near infrared spectroscopy was measured in 24 preterm infants of 28.0 (26.6 -29.3) wk GA [median (interquartile range)] during resuscitation using up to three SIs of 20, 25, and 30 cm H 2 O of 15 s duration each followed by nasal continuous positive airway pressure (CPAP) as first line approach for respiratory support. During positioning and suctioning immediately after delivery infants became progressively hypoxemic and bradycardic before respiratory support was initiated. In 18 infants (75%), more than one SI were applied. During the last SIs, there was a rapid increase in the infants' heart rate and an increase in cerebral tissue oxygen saturation. Arterial saturation increased with slight delay. In conclusion, effective last sustained inflations increase heart rate and cerebral tissue oxygen saturation to be followed by an increase in arterial saturation. (Pediatr Res 70: 176-180, 2011) R eplacement of amniotic fluid by air to establish a gaseous functional residual capacity (FRC) is essential for successful transition after birth (1,2). Term and preterm infants begin to breathe after delivery with deep inspirations and braking of expirations (3-7). Closure of the larynx during expiration may help the newborn to maintain FRC (6,8).Clinical and laboratory observations have shown that the application of continuous positive airway pressure (CPAP) helps to establish a gaseous FRC and improve gas exchange (9 -11). In a preterm animal model, the application of SIs of 10 to 20 s duration did further enhance movement of amniotic fluid into the distal airways resulting in an increased FRC and more uniform lung aeration than CPAP alone (10,12).Clinical studies suggest that the use of SIs in preterm infants may help to reduce the need for intubation and mechanical ventilation without adverse effects (13,14). A lower rate of bronchopulmonary dysplasia (BPD) was reported in one study when SIs followed by nasal CPAP was compared with bag and mask ventilation (13). However, these trials have limited power to prove safety of SIs.Possible sequelae of SIs include overdistension of the lung and compromise of hemodynamics as a result of the impaired systemic venous return and decreased pulmonary blood flow caused by the increase in intrathoracic pressure during the procedure (15-18). Cerebral blood flow may be impaired resulting in brain damage in the preterm infant (19 -21). Impaired cerebral venous flow may predispose to intraventricular hemorrhage (IVH) (22) or periventricular hemorrhagic infarction (23,24).Near-infrared spectros...

Cerebral Near-Infrared Spectroscopy during Transition of Healthy Term Newborns

“…However, differences in SpO 2 and heart rate change between preterm and term infants were small; therefore, too deliberate use of oxygen seems not likely. However, the use of sustained inflations causing a very quick rise in heart rate and SpO 2 might have contributed to the faster transition in the preterm infants [9]. Nevertheless, monitoring of an adequate cerebral oxygen delivery by NIRS may help to avoid unnecessary aggressive delivery room care such as excessive use of oxygen or invasive mechanical ventilation.…”

“…This technique may provide useful information for the prevention of brain damage during transition from fetal to neonatal life [3,4]. Data on cerebral oxygenation during the transition of term and preterm infants have become available recently, including measurement of c StO 2 in term infants after spontaneous delivery [5,6], in term infants after caesarean section (CS) [7,8] and, more recently, in very-low-birth-weight infants (VLBW) [3,9]. Differences in absolute values of c StO 2 appear to exist between these groups.…”

“…We recently reported c StO 2 in VLBW infants after birth [3,9]. We were interested to compare the data of these infants that required assistance for stabilization to values from normal healthy term infants.…”

Brain oxygenation monitoring during neonatal resuscitation of very low birth weight infants

“…Direct impact of sustained inflations on cerebral oxygenation from a subgroup of this cohort of preterm infants has been reported elsewere. 22 …”

How to Monitor the Brain during Immediate Neonatal Transition and Resuscitation: A Systematic Qualitative Review of the Literature

“…Six studies described sequential measurements of cerebral perfusion using Doppler sonography (table 2) [13,14,15,16,17,18], one of them using continuous monitoring of cerebral tissue oxygenation with near-infrared spectroscopy (NIRS) [17]. Fifteen studies described cerebral oxygenation during neonatal transition using NIRS (table 3) [17,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. One of these studies continuously monitored cerebral activity using amplitude-integrated electroencephalography (aEEG) [32].…”