Evaluating Manual Inflations and Breathing during Mask Ventilation in Preterm Infants at Birth

doi:10.1016/j.jpeds.2012.09.036

The Journal of Pediatrics

Volume 162, Issue 3, March 2013, Pages 457-463

https://doi.org/10.1016/j.jpeds.2012.09.036 Get rights and content

Objective

To investigate inflations (initial sustained inflations and consecutive inflations) and breathing during mask ventilation in preterm infants at birth.

Study design

Resuscitation of infants <32 weeks' gestation receiving mask ventilation at birth were recorded. Recorded waveforms were divided into inflations (sustained and consecutive inflations), breaths in between inflations, breaths coinciding with an inflation, and breaths on continuous positive airway pressure (during evaluation moments in between and after ventilation) and expiratory tidal volume (V_Te) was compared. Inflations were analyzed for leak, low V_Te (<2.5 mL/kg), high V_Te (>15 mL/kg in sustained inflations, >10 mL/kg in consecutive inflations), and airway obstruction.

Results

In 27 infants, we analyzed 1643 inflations, 110 breaths in between inflations, 133 breaths coinciding with an inflation, and 1676 breaths on continuous positive airway pressure. A large mask leak frequently resulted in low V_Te. Breathing during positive pressure ventilation occurred in 24 of 27 infants (89%). Median (IQR) V_Te of inflations, breaths in between inflations, and breaths coinciding with an inflation were 0.8 mL/kg (0.0-5.6 mL/kg), 2.8 mL/kg (0.7-4.6 mL/kg), and 3.9 mL/kg (0.0-7.7 mL/kg) during sustained inflations and 3.7 mL/kg (1.4-6.7 mL/kg), 3.3 mL/kg (2.1-6.6 mL/kg), and 4.6 mL/kg (2.1-7.8 mL/kg) during consecutive inflations, respectively. The V_Te of breaths were significantly lower than the V_Te of inflations or breaths coinciding with an inflation.

Conclusions

We often observed large leak and low V_Te, especially during sustained inflations. Most preterm infants breathe when receiving mask ventilation and this probably contributed to the stabilization of the infants after birth.

Section snippets

Methods

This prospective observational study was performed at the Department of Neonatology in the Leiden University Medical Center, a tertiary-level perinatal care center. The study was approved by the Institutional Review Board of the Leiden University Medical Center. The use of a resuscitation monitor and oximeter is advised in the neonatal resuscitation guidelines of the Leiden University Medical Center and is considered as standard of care when time allows us to set up the equipment. Parental

Results

From March 2009 to October 2010, we recorded 57 resuscitations of preterm infants with a median (IQR) GA of 29 (27-31) weeks and birth weight 1200 g (985-1418 g). Fourteen infants (52%) were male, 18 (67%) were born by cesarean delivery, and 17 (63%) had received antenatal steroids. Thirty were excluded because they did not meet the inclusion criteria for this study: in 14 infants (25%), a nasopharyngeal tube was used as interface, 8 received only CPAP (median [IQR] GA 30 weeks [29-31 weeks]),

Discussion

We analyzed 3562 breaths and inflations of 27 preterm infants in detail. When investigating the effect of inflations alone, we found our results showed that mask ventilation was frequently hampered by large mask leakage, leading to low V_Te. Airway obstruction or high V_Te occurred less often. We observed breathing by preterm infants receiving mask ventilation during both sustained inflations and consecutive inflations. The V_Te of breaths was significantly lower than the V_Te of inflations or

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The vocal cords are predominantly closed in preterm infants <30 weeks gestation during transition after birth; an observational study
2024, Resuscitation
Studies in animals have shown that vocal cords (VCs) close during apnoea before and after birth, thereby impairing the effect of non-invasive ventilation. We tested the feasibility of visualising VCs using ultrasonography (US) and investigated the position and movement of the VCs during non-invasive respiratory support of preterm infants at birth.
In an observational study, VCs were visualised using US in infants <30 weeks gestation during both stabilisation after birth and at one hour after birth. Respiratory efforts were simultaneously recorded. The percentage of time the VCs were closed in the first ten minutes was determined from videoframes acquired at 15 Hz and compared with respiratory flow patterns measured using a respiratory function monitor.
US of the VCs could be performed in 20/20 infants included (median (IQR) gestational age 27⁺⁶ (27⁺¹–28⁺⁶) weeks) without interfering with stabilisation, of whom 60% (12/20) were initially breathing and 40% (8/20) were apnoeic at birth. In breathing infants, the VCs closed between breaths and during breath holds, which accounted for 57% (49–66) of the time. In apnoeic infants receiving positive pressure ventilation, the VCs were closed for 93% (81–99) of the time. US at one hour after birth could be performed in 14/20 infants, VCs were closed between breaths and during breath holds, accounting for 46% (27–52) of the time.
Visualising VCs in preterm infants at birth using US is feasible. The VCs were closed during apnoea, in between breaths and during breath holds, impairing the effect of ventilation given.
Use of laryngeal mask for neonatal resuscitation in Brazil: A national survey
2023, Resuscitation Plus
Citation Excerpt :
When promptly initiated, positive pressure ventilation (PPV) is sufficient to reestablish the cardiovascular status in 90% of the patients.2 However, PPV can often be ineffective mainly because of the leaks around the ill-fitting face mask (FM), requiring tracheal intubation,3,4 which is a complex and invasive procedure requiring specific professional training and experience.5 The laryngeal mask (LMA) is an alternate option to provide lung ventilation to the newborns in the delivery room.
The International Liaison Committee on Resuscitation suggests using the laryngeal mask airway (LMA) as an alternative to the face mask for performing positive pressure ventilation (PPV) in the delivery room in newborns ≥34 weeks. Because not much is known about the health professionals’ familiarity in using LMA in Brazil, this study aimed to describe the health professionals’ knowledge and practice of using LMA, who provide neonatal care in the country.
An online questionnaire containing 29 questions was sent to multi-healthcare professionals from different regions in the country through email and social media groups (WhatsApp®, Instagram®, Facebook®, ^and LinkedIn®). The participants anonymously answered the questions regarding their knowledge and expertise in using LMA to ventilate newborns in the delivery room.
We obtained 749 responses from all the regions in Brazil, with 80% from health professionals working in public hospitals. Most respondents were neonatologists (73%) having > 15 years of clinical practice. Among the respondents, 92% recognized the usefulness of LMA for performing PPV in newborns, 59% did not have specific training in LMA insertion, and only 8% reported that they have already used LMA in the delivery room. In 90% of the hospitals, no written protocol was available to use LMA; and in 68% of the hospitals, LMA was not available for immediate use.
This nationwide survey showed that most professionals recognize the usefulness of LMA. However, the device is scarcely available and underused in the routine of ventilatory assistance for newborns in delivery rooms in Brazil.
Technology in the delivery room supporting the neonatal healthcare provider's task
2022, Seminars in Fetal and Neonatal Medicine
Very preterm infants are a unique and highly vulnerable group of patients that have a narrow physiological margin within which interventions are safe and effective. The increased understanding of the foetal to neonatal transition marks the intricacy of the rapid and major physiological changes that take place, making delivery room stabilisation and resuscitation an increasingly complex and sophisticated activity for caregivers to perform. While modern, automated technologies are progressively implemented in the neonatal intensive care unit (NICU) to enhance the caregivers in providing the right care for these patients, the technology in the delivery room still lags far behind. Diligent translation of well-known and promising technological solutions from the NICU to the delivery room will allow for better support of the caregivers in performing their tasks. In this review we will discuss the current technology used for stabilisation of preterm infants in the delivery room and how this could be optimised in order to further improve care and outcomes of preterm infants in the near future.
Respiratory monitoring during neonatal resuscitation using a supraglottic airway device vs. a face mask
2022, Resuscitation
Citation Excerpt :
Still, it is challenging to perform, and the implementation of neonatal resuscitation educational programs show discordant results.9,10 The major obstacles to effective FM ventilation are mask leakage,11–14 airway obstruction,5 and unnecessary pauses during PPV.15 The current evidence suggests that neonatal laryngeal mask airway and supraglottic airway (SGA) are a safe alternative to face mask ventilation (FMV).16–18
To evaluate the respiratory function of asphyxiated infants resuscitated with i-gel supraglottic airway (SGA) vs. face mask (FM) in a low-resource setting.
In this sub-study from the NeoSupra trial, respiratory function during the first 60 inflations was evaluated in 46 neonates (23 with SGA and 23 with FM) at the Mulago National Referral Hospital, Uganda. The primary outcome was the mask leak (%). The secondary outcomes included inspired (VTi) and expired (VTe) tidal volumes, and heart rate response to ventilation.
Median mask leak was 40% (IQR 22–52) with SGA and 39% (IQR 26–62) with FM (p = 0.38). Median VTe was 7.8 ml/kg (IQR 5.6–10.2) with SGA and 7.3 ml/kg (IQR 4.8–11.9) with FM (p = 0.84), while median VTi was 15.4 ml/kg (IQR 11–4-17.6) with SGA and 15.9 ml/kg (IQR 9.0–22.6) with FM (p = 0.68). A shorter time was needed to achieve heart rate > 100 bpm in SGA (median 13 s IQR 9–15) with respect to FM arm (median 61, IQR 33–140) (p = 0.0002).
Respiratory function was not statistically different between neonates resuscitated with SGA vs. FM. SGA was associated with faster heart rate recovery compared to FM in the subgroup of neonates with bradycardia. Further research is needed to investigate possible advantages of SGA on respiratory function at birth.
Delivery room stabilization and respiratory support
2022, Goldsmith's Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care, Seventh Edition
Sustained Inflation Versus Intermittent Positive Pressure Ventilation for Preterm Infants at Birth: Respiratory Function and Vital Sign Measurements
2021, Journal of Pediatrics
To characterize respiratory function monitor (RFM) measurements of sustained inflations and intermittent positive pressure ventilation (IPPV) delivered noninvasively to infants in the Sustained Aeration of Infant Lungs (SAIL) trial and to compare vital sign measurements between treatment arms.
We analyzed RFM data from SAIL participants at 5 trial sites. We assessed tidal volumes, rates of airway obstruction, and mask leak among infants allocated to sustained inflations and IPPV, and we compared pulse rate and oxygen saturation measurements between treatment groups.
Among 70 SAIL participants (36 sustained inflations, 34 IPPV) with RFM measurements, 40 (57%) were spontaneously breathing prior to the randomized intervention. The median expiratory tidal volume of sustained inflations administered was 5.3 mL/kg (IQR 1.1-9.2). Significant mask leak occurred in 15% and airway obstruction occurred during 17% of sustained inflations. Among 34 control infants, the median expiratory tidal volume of IPPV inflations was 4.3 mL/kg (IQR 1.3-6.6). Mask leak was present in 3%, and airway obstruction was present in 17% of IPPV inflations. There were no significant differences in pulse rate or oxygen saturation measurements between groups at any point during resuscitation.
Expiratory tidal volumes of sustained inflations and IPPV inflations administered in the SAIL trial were highly variable in both treatment arms. Vital sign values were similar between groups throughout resuscitation. Sustained inflation as operationalized in the SAIL trial was not superior to IPPV to promote lung aeration after birth in this study subgroup.
Clinicaltrials.gov: NCT02139800.

View all citing articles on Scopus

: A.tP. is a recipient of the Veni-grant from The Netherlands of Health Research and Development (ZonMw) and part of the Innovation Research Incentives Scheme Veni-Vidi-Vici (project number 91612027). The authors declare no conflicts of interest.

^∗: Contributed equally.

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Original ArticleEvaluating Manual Inflations and Breathing during Mask Ventilation in Preterm Infants at Birth

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Circulation

Ventilation of the preterm neonate in the delivery room

Curr Pediatr Rev

A randomized, controlled trial of delivery-room respiratory management in very preterm infants

Pediatrics

Leak and obstruction with mask ventilation during simulated neonatal resuscitation

Arch Dis Child Fetal Neonatal Ed

Improved techniques reduce face mask leak during simulated neonatal resuscitation: study 2

Arch Dis Child Fetal Neonatal Ed

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

Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room

Arch Dis Child Fetal Neonatal Ed

Airway obstruction and gas leak during mask ventilation of preterm infants in the delivery room

Arch Dis Child Fetal Neonatal Ed

Lung injury in neonates: causes, strategies for prevention, and long-term consequences

J Pediatr

Mechanisms initiating lung injury in the preterm

Early Hum Dev

Reducing lung injury during neonatal resuscitation of preterm infants

J Pediatr

Crying and breathing by extremely preterm infants immediately after birth

J Pediatr

Assessment of chest rise during mask ventilation of preterm infants in the delivery room

Resuscitation

Clinical practice: neonatal resuscitation. A Dutch consensus

Eur J Pediatr

Ventilation and spontaneous breathing at birth of infants with congenital diaphragmatic hernia

J Pediatr

Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep

Am J Respir Crit Care Med

Original Article
Evaluating Manual Inflations and Breathing during Mask Ventilation in Preterm Infants at Birth