Sustained Inflation and Its Role in the Delivery Room Management of Preterm Infants

Abstract

A noninvasive approach in the delivery room in place of intubation and mechanical ventilation can reduce rates of bronchopulmonary dysplasia and death. Nevertheless, the rate of nasal continuous positive airway pressure failure still remains high. In order to prevent lung injury and to enhance the success of continuous positive airway pressure, sustained inflation (administration by face mask or nasopharyngeal tube of a high peak pressure of 20-25 cm H₂O, maintained for 10-15 s) has been recently proposed to establish an early and efficient functional residual capacity in the delivery room. Sustained inflation is an intriguing therapy, although the results of clinical trials are controversial in terms of respiratory outcomes. A critical role in the success of sustained inflation could be the presence of open or closed glottis and the contribution of spontaneous breathing that allows air to enter the lungs during the maneuver. Recent neonatal resuscitation guidelines suggest that sustained inflation may be considered in individual clinical circumstances or research settings.

Sustained lung inflation at birth via short binasal prong in very low birth weight preterm infants: A retrospective study

“…Even with early nCPAP administration after birth in preterm infants with RDS, more time is required to attain adequate FRC and lung recruitment when compared with SLI.1 Furthermore, SLI and nCPAP enhance one another in creating adequate FRC, thus leading to improved lung mechanics, optimal gas exchange, and less need for respiratory support . The current practice in delivery rooms is to apply positive end‐expiratory pressure (PEEP) with IPPV for preterm infants who do not breathe spontaneously, and use only nCPAP for infants breathing spontaneously .…”

“…However, respiratory failure occurs in up to 50% of infants given nCPAP as initial respiratory support . In order to prevent lung damage and increase nCPAP success, SLI is recommended for preterm infants with respiratory failure and RDS to ensure early and effective creation of FRC . Especially in preterm infants with spontaneous breathing at birth, achieving early and adequate FRC and then maintaining sufficient lung volume with nCPAP seems to be a crucial initial strategy for the success of NIV respiratory support .…”

Sustained inflations and avoiding mechanical ventilation to prevent death or bronchopulmonary dysplasia: a meta-analysis

“…The meta-analysis of six RCTs including 854 preterm infants of <33 weeks' gestational age showed no effects of sustained inflations on BPD, death or the combined outcome of death or BPD (figure 3). This could be due to inefficiency of sustained inflations in infants who remained apnoeic after birth [6], or due to excessive pressure and duration of the sustained inflations, with subsequent inflammatory response in the lungs [29]. Notably, the duration of sustained inflations was guided by exhaled carbon dioxide monitoring in one RCT, but this did not improve outcomes [12].…”

“…Consequently, new interventions to prevent BPD are urgently needed, and there is a consensus that appropriate measures should start in the delivery room [2,5]. Sustained inflations and avoiding endotracheal mechanical ventilation (eMV) are promising respiratory interventions to reduce BPD in the delivery room and have been investigated in randomised controlled trials (RCTs) [2,6].…”

Sharing Progress in Neonatal (SPIN) Lung and Brain

“…The next two invited speakers from Italy discussed different forms of non-invasive ventilation [12,13]. Corrado Moretti from Rome spoke about synchronised intermittent positive pressure ventilation, concentrating on technical issues and clinical outcomes, whereas Gianluca Lista from Milan discussed the place of sustained inflation in the delivery room management of preterm infants.…”