Noninvasive Ventilation in the Delivery Room for the Preterm Infant

Heather Weydig, MD,* Noorjahan Ali, MD, MS,* Venkatakrishna Kakkilaya, MD* *Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX

Education Gaps

The preterm lung is highly susceptible to injury from exposure to mechanical ventilation in the delivery room. It is important to use optimal noninvasive ventilation strategies and continuous positive airway pressure to establish functional residual capacity during resuscitation to avoid intubation and mechanical ventilation.

Abstract

A decade ago, preterm infants were prophylactically intubated and mechanically ventilated starting in the delivery room; however, now the shift is toward maintaining even the smallest of neonates on noninvasive respiratory support. The resuscitation of very low gestational age neonates continues to push the boundaries of neonatal care, as the events that transpire during the golden minutes right after birth prove ever more important for determining long-term neurodevelopmental outcomes. Continuous positive airway pressure (CPAP) remains the most important mode of noninvasive respiratory support for the preterm infant to establish AUTHOR DISCLOSURE Drs Weydig, Ali, and maintain functional residual capacity and decrease ventilation/perfusion and Kakkilaya have disclosed no financial relationships relevant to this article. This mismatch. However, the majority of extremely low gestational age infants commentary does not contain a discussion of require face mask positive pressure ventilation during initial stabilization an unapproved/investigative use of a commercial product/device. before receiving CPAP. Effectiveness of face mask positive pressure ventilation depends on the ability to detect and overcome mask leak and ABBREVIATIONS airway obstruction. In this review, the current evidence on devices and BPD bronchopulmonary dysplasia techniques of noninvasive ventilation in the delivery room are discussed. CPAP continuous positive airway pressure DR delivery room

EtCO2 end-tidal carbon dioxide FRC functional residual capacity After completing this article, readers should be able to: GA gestational age Objectives HFNC high-flow nasal cannula 1. Describe the fetal to neonatal transition in the lung. IVH intraventricular hemorrhage NRP neonatal resuscitation program 2. Explain the importance of establishing functional residual capacity for PEEP positive end-expiratory pressure successful noninvasive respiratory support. PIP peak inspiratory pressure PPV positive pressure ventilation 3. Describe the modes of noninvasive respiratory support and list the devices RCT randomized controlled trial used for premature infants at time of birth. SI lung inflation

VT tidal volume

Vol. 20 No. 9 SEPTEMBER 2019 e489 Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 FETAL TO NEONATAL TRANSITION continuous positive airway pressure (CPAP) decreases the composite outcome of death or BPD. (11)(12) DR manage- The critical period of fetal lung development occurs during ment for the premature infant may have an extremely the canalicular to saccular stages. Premature infants are important effect on survival and survival without severe born in this critical period and therefore are at highest risk illness. (13)(14) These findings have resulted in a practice for lung underdevelopment and injury. For the lung to change, with an increasing number of infants in the DR develop properly, the lung must be fluid-filled. In utero, being stabilized on CPAP. (15)(16)(17) The aim of this article the fetal lung epithelium secretes liquid, allowing for the is to provide an updated review of noninvasive devices and lungs to be fluid-filled. (1)(2) With the help of a closed fetal strategies used in the DR for premature infants (Table 1). larynx that prevents fluid from flowing out of the lung, the fluid creates lung expansion that is important for the nor- mal development of the lung. During this time, fetal gas INTERFACES FOR DELIVERING NONINVASIVE PPV IN THE DR exchange relies solely on the placenta. (1)(2) The low oxygen tension in the alveoli results in a state of constant pulmonary Face Mask vasoconstriction in the fetus, which diverts blood from the Administration of noninvasive PPV via face mask is the lungs to the systemic circulation. current standard of care. Two different types of masks are As gestation advances, multiple changes prepare the available for use: an anatomic shaped mask and a round fetal lung for an ex utero environment, including the differ- mask. Face mask PPV is dependent on achieving an ade- entiation of type I and II pneumocytes, the secretion of quate seal to avoid mask leak. Commercially available masks surfactant to reduce alveolar surface tension, and the mod- vary in shape and size (Fig 1). Palme et al compared 5 widely fi i cation of epithelial sodium channels. Signals around the used round and triangular masks for mask leak in 44 time of birth lead to an increase in catecholamine release newborns in the DR. (18) They assessed the percentage fl that downregulates uid secretion by the lung epithelium of leak by calculating the difference between set pressure fl and stimulates uid resorption by the sodium channels, and the average peak pressure. This study reported less leak fl fi fi changing the lungs from uid- lled to gas- lled. (1) Once with the use of the round silicone mask compared with the fi the lung is gas- lled, the oxygen tension increases and leads triangular mask. (18) However, O’Donnell et al compared – to nitric oxide mediated pulmonary vasodilation and gas round and anatomic masks using mannequins and found exchange. At birth, all of these pulmonary changes help to no difference in the air leak between the 2 different mask facilitate the neonatal lung in establishing functional resid- types. (19) ual capacity (FRC). However, several factors impede the O’Shea et al evaluated the facial measurements of pre- development of adequate FRC among preterm infants, term infants born between 24 and 33 weeks’ GA and fi including immature lung parenchyma, surfactant de - suggested that masks of 35-mm diameter are suitable ciency, a compliant chest wall, slower lung fluid clearance, for infants of less than 29 weeks’ GA and 42-mm diameter weak respiratory muscle, poor laryngeal tone leading to masks are suitable for infants between 27 and 33 weeks’ decreased ability to grunt, and an immature respiratory GA. Interestingly, the standard commercially available face drive. (3)(4)(5) Preterm infants often require positive pres- mask measures 50 mm while small round face masks are sure ventilation (PPV) soon after birth because of poor FRC available in 35-mm and 42-mm inner diameter sizes. (20) and ineffective respiration that may be associated with The correct mask size should be determined by placing the bradycardia. bottom of the mask on the tip of the chin to cover the While the majority of preterm infants (65%–77%) born at mouthandthenosebutthetopofthemasknotreaching less than 28 weeks’ gestational age (GA) require PPV in the the eyes. However, a recent RCT that measured the mask delivery room (DR), (6)(7) they are also the most vulnerable leak using respiratory function monitoring did not show to the adverse consequences that may arise from exposure to any difference in the mask leak between standard and

PPV. Even brief exposure to large tidal volume (VT) breaths small round masks. (21) can initiate an inflammatory cascade that alters lung archi- There are several ways to hold the face mask (Fig 2). A tecture and contributes to the development of bronchopul- recent study looking at corrective ventilation strategies for monary dysplasia (BPD). (8)(9)(10) Meta-analyses of large, infants of less than 32 weeks’ GA in the DR found that the multicenter, randomized controlled trials (RCTs) that eval- most frequent mask holds were 1-handed (95%), 2-handed uated invasive and noninvasive respiratory support in the (63%), stem hold (23%), and modified spider hold (6%). (22) DR show that avoiding intubation and stabilizing infants on The mask hold also depends on the face mask that is being

e490 NeoReviews Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 more leak and tube obstruction with the nasal tube com- Delivery Room Interfaces and Devices TABLE 1. pared with a face mask. (24) In addition, using the nasal tube for Resuscitation delayed PPV initiation because of placement of the tube, and was also noted to be associated with inadequate V . (24) Interfaces for delivering positive pressure ventilation T • Face mask (anatomical shaped vs round) Short Binasal Prongs • Single nasal tube Although binasal prongs are widely used to provide CPAP in • Short binasal prongs the DR, the experience with its application for providing Pressure delivery devices for delivering positive PPV in the DR is limited. To date, the RAM Cannula pressure ventilation (Neotech, Valencia, CA) is the only nasal prong that is able • T-piece resuscitator to directly interface with the T-piece resuscitator. A single- • Flow-inflating bag center retrospective study reported a decrease in DR intu- bation rate after instituting these particular short binasal prongs • Self-inflating bag to provide noninvasive ventilation compared with historical cohorts who were resuscitated with a face mask. (25) However, theoretical concerns exist including possible higher intrinsic resistance (26) and insignificant V delivery with ventilator- used, because a different hold may be necessary for the T delivered noninvasive positive pressure breaths. (27) silicone face mask versus the bubble face mask. In summary, there is no current evidence to suggest one There is a theoretical concern that when the face mask is mask is better than another for neonatal DR resuscitation, placed, it overlies the nasotrigeminal area and can influence although mask size is important. Other interface options ventilation by stimulating the trigeminal nerve, resulting in such as a single nasal tube and short binasal prongs need to cessation of a normal breathing pattern, bradycardia, periph- be evaluated further in well-designed RCTs before being eral vasoconstriction, and closure of the larynx. (23) This adopted for routine clinical practice. Simulation-based train- further necessitates proper face mask positioning and size to ing has been shown to decrease mask leak and improve the limit stimulation of this nerve. effectiveness of face mask PPV.

Single Nasal Tube MODES OF NONINVASIVE RESPIRATORY SUPPORT IN To overcome the shortcomings of the face mask, other THE DR interfaces such as nasal tubes and short binasal prongs are being studied for the delivery of noninvasive ventilation. Positive Pressure Ventilation A nasal tube is a single tube that enters one nare and ends in The Neonatal Resuscitation Program (NRP) currently rec- the nasopharynx and is used to deliver PPV. Van Vonderen ommends initiating PPV in the DR for bradycardia et al, in their study of 43 infants, used nasal tubes as the (HR<100) and/or when respiratory effort by the neonate primary mode to deliver noninvasive ventilation and found is inadequate. (28) The recommended initial settings are an

Figure 1. Examples of face masks. A. The top row demonstrates anatomic face masks. The bottom row demonstrates round face masks. B. Anatomic masks (mask at far right) have an air-filled balloon whereas round masks (mask at far left and in the middle) have a silicone flap to promote adherence to the face without excessive downward pressure.

Vol. 20 No. 9 SEPTEMBER 2019 e491 Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 Figure 2. Examples of mask holds. A. Stem hold. B. One-handed (“C”) hold.

fl in ation pressure of 20 cm H2O, and positive end-expiratory ventilation with large VT were diagnosed with IVH com-

pressure (PEEP) of 5 cm H2O at a rate of 40 to 60 breaths/ pared with a 13% rate of IVH in the group with a VT less than min, with the pressure being adjusted depending on the 6 mL/kg. (33) Hinder et al investigated T-piece devices on patient’s response. Response to PPV can be evaluated by mannequins and showed that despite a set PEEP and PIP, improvement in heart rate which can be monitored using the pressure being delivered to the individual neonate electrocardiographic waveforms or pulse oximetry. varied, depending on the changes in lung compliance. There are 3 modes to deliver PPV: a T-piece resuscitator, (34) Hinder et al also found that T-piece devices delivered a self-inflating bag, or a flow-inflating bag (Fig 3), which inadvertent PEEP above the set value, possibly because of a are all approved by NRP to be used for resuscitation in the number of factors, including accidental rotation of the PEEP DR, depending on resources available at the hospital. It knob, finger distance over the PEEP valve, presence of an should be noted that only the flow-inflating bag and T- endotracheal tube, use of surfactant, high airway resistance, piece resuscitator can be used to provide PPV and CPAP. and low delivery gas flowrate. (34) Further studies are Use of a T-piece is gaining favor for DR use because of its needed to verify these findings. ability to deliver controlled pressures. However, 3 RCTs comparing the use of a T-piece resuscitator versus a self- Sustained Lung Inflation inflating bag for ventilation of extremely preterm infants Sustained lung inflation (SI) is the use of distending pres- in the DR did not show improvement in long-term out- sure PIP applied for a certain duration with the goal of comes. (29)(30)(31) A single-center observational study establishing FRC. In animal models, SI performed during comparing the self-inflating bag to the T-piece resuscitator in the first inflations after birth helped to clear liquid from the very-low-birthweight neonates showed that the latter modality airways and helped in establishing FRC. To date, 5 RCTs had an increased hospital survival rate without BPD, intra- have investigated the use of SI in preterm infants using ventricular hemorrhage (IVH), and periventricular leuko- different durations and SI pressures. A meta-analysis com- malacia. (32) paring all patients from these trials showed no significant fi It is dif cult for practitioners to estimate the VT being difference in the rate of BPD or death. (35) Recently, the delivered during PPV despite the use of advanced resusci- Sustained Inflation of Infant Lung (SAIL) trial randomized tation devices such as the T-piece resuscitator. One study 426 extremely preterm infants with bradycardia with inad- showed that of 218 neonates born at less than 29 weeks’ GA equate respiratory effort in 9 countries to either 2 sustained fl resuscitated in the DR, with the T-piece resuscitator set at a in ations to maximal peak pressure of 25 cm H2O for 15 peak inspiratory pressure (PIP) of 24 and PEEP of 6 cm seconds or standard bag and mask. (36) The trial was fi H2O, 75% of patients received ventilation with VT greater stopped early because of increased death in the rst 48 than 6 mL/kg, which can injure the lungs and contribute hours after birth in the sustained inflation group. (36) to IVH. (33) Fifty-one percent of infants who received Currently, there is not enough evidence to recommend

e492 NeoReviews Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 Figure 3. Comparison of devices used to deliver positive pressure ventilation. CPAP¼continuous positive airway pressure; PEEP¼positive end- expiratory pressure; PIP¼peak inspiratory pressure.

routine SI in the DR, and one RCT suggests potential harm an algorithm for the practical use of EtCO2 detectors in with this approach. the DR. Importantly, when a target pressure cannot be obtained despite colorimetry change, this most likely repre- Intervention to Overcome Mask Leak and Airway sents mask leak. Of note, when using a T-piece device with a Obstruction face mask, significant leak can occur while still visualizing the The best evidence that a neonate is receiving effective ven- pressure reading on the manometer. Therefore, visualization tilation after initiation of PPV is a rising heart rate. Most of manometry pressures cannot be used to ensure reliable premature infants will receive PPV in the DR. (6) When the mask seal; practitioners must consider mask leak as a pos- heart rate fails to increase, the first step in troubleshooting sible cause of ineffective PPV whether or not target pressure is to address mechanical issues such as airway obstruction readings are obtained on the T-piece resuscitator. and mask leak. Premature infants are placed in plastic bags After recognition of ineffective ventilation, NRP advises the for thermoregulation and it is often difficult to assess chest use of the “MRSOPA” mnemonic to further correct ventilatory rise through the bag. (37) To diagnose the potential issue steps in a neonate with a decreasing heart rate. (28) Mask leading to ineffective PPV, some studies suggest that the use adjustment, repositioning the airway, suctioning, opening the of colorimetric end-tidal carbon dioxide (EtCO2) detection mouth, increasing inspiratory pressure, and alternate airway during face mask ventilation may be beneficial. Using a (MRSOPA) are the most important steps in correcting venti- disposable EtCO2 detector attached to a face mask dur- lation. One observational study on the frequency and use of ing PPV, providers can assess the patency of the airway. MRSOPA strategies in the DR found that infants less than 32 ’ (38)(39)(40)(41) In one observational study using EtCO2 weeks gestation who received more MRSOPA interventions detectors, 18 infants received a median of 14 obstructed were more likely to be intubated. (22) However, a quality fi breaths de ned by no color change on the EtCO2 despite improvement project reported decreased DR intubation rates reaching a target pressure. (38) The authors concluded that andimprovedoutcomeswithsimulation-based peer-to-peer airway obstruction is extremely common in very-low-birthweight training on MRSOPA strategies by using small round masks, infants and that EtCO2 detectors can help recognize this EtCO2 detectors, increasing pressure, and increasing inspira- obstruction. (38) In addition, in the neonate undergoing tory time to 1 second when indicated. (17) Wood et al reported PPV with good chest rise, but continued bradycardia leading that team training using written instruction and photographs to poor cardiac output and insufficient carbon dioxide delivery of the optimal techniques can help decrease mask leak during tothelungs,EtCO2 detectors may not change. This was found PPV. (43) Such interventions to improve ventilation via correc- in a piglet model in which low quantitative EtCO2 values tive steps conducted in individual centers can help decrease the were directly related to low cardiac output states, leading need for intubation and increase stabilization of infants receiv- to decreased pulmonary blood flow. (42) Figure 4 describes ing noninvasive respiratory support in the DR.

Vol. 20 No. 9 SEPTEMBER 2019 e493 Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 Figure 4. Using end-tidal carbon dioxide (CO2) detectors attached to a face mask in the delivery room can help detect an obstructed airway. HR¼heart rate; PPV¼positive pressure ventilation; MRSOPA¼mask adjustment, repositioning the airway, suctioning, opening the mouth, increasing inspiratory pressure, and alternate airway.

CPAP for DR Resuscitation rate of 8 to 10 L/min. Both bubble CPAP and the adjustable PEEP CPAP has been widely used for the respiratory support of valve can be used with binasal prongs of many different types or preterm infants in the NICU over the last 5 decades. small nasal masks. Ventilators are commonly used for CPAP (28)(44) CPAP increases FRC, (44) decreases airway resis- delivery during transport and in the NICU rather than in the DR. tance, (45) decreases thoracoabdominal asynchrony, (46) and Interfaces. Although the face mask was routinely used to decreases intrapulmonary shunting, (44) thus leading to better administer CPAP to infants with respiratory distress syn- oxygenation and ventilation in spontaneously breathing pre- drome in the 1970s, it fell out of favor because of the difficulty term infants. In addition, CPAP helps decrease obstructive in maintaining a proper seal. (53) However, CPAP is com- apnea (47) and augments surfactant production. (48) The devices monly administered with the T-piece resuscitator with the and interfaces of CPAP use in the DR are listed in Table 2. face mask in the DR because of the ability to provide PPV Constant-Flow CPAP Devices. T-piece resuscitator use when indicated. As discussed before, maintaining a proper with a face mask is recommended by NRP for CPAP delivery in seal is important to provide the desired CPAP level. In the DR. (49) The desired PEEP level can be adjusted at the PEEP addition, the increased dead space of the face mask also valve. The T-piece is used with a face mask, single nasal tube, or may decrease the effectiveness of CPAP delivery. (54) specific type of short binasal prongs (RAM cannula). Bubble CPAP Binasal prong CPAP has been effectively used since 1973. uses the water column at the end of the expiratory limb to generate (50)(55) De Paoli et al demonstrated that short binasal pressure in the CPAP circuit. CPAP level is determined by the prongs offered the lowest resistance to flow compared with immersion length of the expiratory tubing. (50) The gas exiting the single nasal tube. (56) Prong size is an important from the underwater tubing creates bubbles. Bubbling may pro- consideration because the smaller prongs may generate vide additional benefits with mechanisms such as stochastic higher resistance to flow. (56)(57) Small nasal masks can resonance (51) and high-frequency oscillatory waveforms (52) in be used as an alternative to binasal prongs. Recently, Green improving gas exchange and lung recruitment. CPAP can also be et al reported that these small nasal masks pose less intrinsic delivered in the DR using an adjustable PEEP valve connected to resistance compared with short binasal prongs. (26) the expiratory limb of the CPAP circuit. The inspiratory limb is CPAP Delivery in the DR. Face mask CPAP provided at

connected to the gas source from the blender, usually set at a flow 5cmH2O using a T-piece generator should be initiated at

e494 NeoReviews Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 determined by the flow rate, size of the nasal cannula, and CPAP Devices and Interfaces for DR TABLE 2. amount of leak from the nose and mouth. (61)(62) Only 1 Resuscitation study has demonstrated the feasibility of using HFNC in the DR for infants between 23 and 29 weeks’ GA. (63) HFNC in Constant flow CPAP generators the DR is not recommended before well-designed RCTs. • T-piece resuscitator • Bubble CPAP SUMMARY • Adjustable PEEP valve • Ventilator During the delivery of premature infants, the DR can often be chaotic, given that premature deliveries could happen Interfaces unexpectedly. A skilled resuscitation team is necessary to • Face mask provide initial lifesaving breaths to this vulnerable popula- • Single nasal tube tion to quickly and effectively establish FRC. After estab- • Binasal prongs lishment of FRC, maintaining neonates on CPAP to prevent lung injury with mechanical ventilation is well-studied. • Small nasal masks However, providing noninvasive ventilation can have chal- CPAP¼continuous positive airway pressure; PEEP¼positive end-expiratory lenges including mask leak, incorrect mask size, and airway pressure. obstruction. Use of a properly sized mask with a colori-

metric EtCO2 detector provides early feedback for airway obstruction and mask leak, though RCTs are still needed. Performing MRSOPA in the event of ineffective ventilation birth for all spontaneously breathing infants. Face PPV is the most important step to ensure the successful transi- should be provided when the infant has bradycardia, poor tion from PPV to CPAP in the DR. respiratory effort, or both. CPAP should be restarted when the infant shows spontaneous respiratory effort and a stable heart rate. Manometer reading and EtCO2 detectors can help in identifying mask leak while administering CPAP. Fraction of inspired oxygen is titrated using the NRP algo- rithm. (49) Although the titration of CPAP level in DR American Board of Pediatrics resuscitation has not been evaluated in clinical trials, one Neonatal-Perinatal Content large RCT that routinely used 8 cm H2O reported a higher fi rate of pneumothoraces. (58) Subsequent trials that used Speci cations • Know the indications for assisted ventilation, including CPAP levels of 5 to 7 cm H2O did not report higher rates of pneumothorax. (6) Higher CPAP levels can help achieve continuous positive airway pressure, immediately after birth and how to assess its effectiveness. higher FRC. (44)(59) Therefore, CPAP level may be titrated • Understand how to use self-inflating and flow-inflating bags or T- higher—up to 7 cm H O for infants requiring higher 2 piece resuscitators to provide assisted ventilation immediately supplemental oxygen in the DR. When the infant demon- after birth. strates regular respiration, stable heart rate, and stable • Know the mechanism of production and factors affecting the oxygen saturation, the infant can be transitioned to either clearance of fetal lung liquid, its contribution to amniotic fluid, binasal prong or small nasal mask for transport to the NICU. and its importance to fetal lung development. CPAP can be provided during transport in multiple ways, • Know the effects of surface tension on alveolar and airway including bubble CPAP, an adjustable PEEP valve using gas stability and lung mechanics (LaPlace law). flow, or ventilator CPAP. When using binasal prongs, it is • Know factors that determine residual lung volume, functional important to use the binasal prong with the largest inner residual capacity, and tidal volume, and how they change with diameter that can snugly fill the nares. various pulmonary disorders. • Know the clinical features of an infant with airway obstruction. • High-Flow Nasal Cannula Know the indications for and techniques of continuous positive airway pressure (CPAP). High-flow nasal cannula (HFNC) delivers heated and • Know the effects and risks of CPAP. humidified gas that aids in gas exchange by minimizing dead space. (60) The pressure that is generated by HFNC is

Vol. 20 No. 9 SEPTEMBER 2019 e495 Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 References 19. O’Donnell CP, Davis PG, Lau R, Dargaville PA, Doyle LW, Morley CJ. Neonatal resuscitation 2: an evaluation of manual ventilation devices and face masks. Arch Dis Child Fetal Neonatal Ed. 1. te Pas AB, Davis PG, Hooper SB, Morley CJ. From liquid to air: 2005;90(5):F392–F396 breathing after birth. J Pediatr. 2008;152(5):607–611 20. O’Shea JE, Thio M, Owen LS, Wong C, Dawson JA, Davis PG. 2. Hooper SB, Kitchen MJ, Wallace MJ, et al. Imaging lung aeration Measurements from preterm infants to guide face mask size. Arch – and lung liquid clearance at birth. FASEB J. 2007;21(12):3329 3337 Dis Child Fetal Neonatal Ed. 2016;101(4):F294–F298 3. Heldt GP, McIlroy MB. Distortion of chest wall and work of 21. O’Currain E, Thio M, Dawson JA, Donath SM, Davis PG. diaphragm in preterm infants. J Appl Physiol (1985). Respiratory monitors to teach newborn facemask ventilation: a – 1987;62(1):164 169 randomised trial. Arch Dis Child Fetal Neonatal Ed. 4. Heldt GP, McIlroy MB. Dynamics of chest wall in preterm infants. 2019;fetalneonatal-2018-316118 – J Appl Physiol (1985). 1987;62(1):170 174 22. Kilmartin KC, Finn D, Hawkes GA, et al. Corrective ventilation 5. Obladen M. Factors influencing surfactant composition in the strategies in delivery room resuscitation of preterm infants. Acta newborn infant. Eur J Pediatr. 1978;128(3):129–143 Paediatr. 2018;107(12):2066–2070 6. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD 23. McCulloch PF, Faber KM, Panneton WM. Electrical stimulation of Neonatal Research Network; Finer NN, Carlo WA, Walsh MC, et al. the anterior ethmoidal nerve produces the diving response. Brain Early CPAP versus surfactant in extremely preterm infants. N Engl J Res. 1999;830(1):24–31 – Med. 2010;362(21):1970 1979 24. van Vonderen JJ, Kamlin CO, Dawson JA, Walther FJ, Davis PG, te 7. Finer NN, Carlo WA, Duara S, et al; National Institute of Child Pas AB. Mask versus nasal tube for stabilization of preterm infants Health and Human Development Neonatal Research Network. at birth: respiratory function measurements. J Pediatr. Delivery room continuous positive airway pressure/positive end- 2015;167(1):81–85.e81 expiratory pressure in extremely low birth weight infants: a 25. Biniwale M, Wertheimer F. Decrease in delivery room intubation – feasibility trial. Pediatrics. 2004;114(3):651 657 rates after use of nasal intermittent positive pressure ventilation in 8. Björklund LJ, Ingimarsson J, Curstedt T, et al. Manual ventilation the delivery room for resuscitation of very low birth weight infants. with a few large breaths at birth compromises the therapeutic effect Resuscitation. 2017;116:33–38 of subsequent surfactant replacement in immature lambs. Pediatr 26. Green EA, Dawson JA, Davis PG, De Paoli AG, Roberts CT. – Res. 1997;42(3):348 355 Assessment of resistance of nasal continuous positive airway pressure 9. Hillman NH, Moss TJ, Kallapur SG, et al. Brief, large tidal volume interfaces [published online ahead of print December 19]. Arch Dis ventilation initiates lung injury and a systemic response in fetal Child Fetal Neonatal Ed. 2018. doi: 10.1136/archdischild-2018-315838 – sheep. Am J Respir Crit Care Med. 2007;176(6):575 581 27. Matlock DN, Bai S, Weisner MD, et al. Tidal volume transmission 10. Hillman NH, Kallapur SG, Pillow JJ, et al. Airway injury from during non-synchronized nasal intermittent positive pressure initiating ventilation in preterm sheep. Pediatr Res. ventilation via RAM cannula. J Perinatol. 2019;39(5):723–729 – 2010;67(1):60 65 28. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal 11. Fischer HS, Bührer C. Avoiding endotracheal ventilation to prevent Resuscitation: 2015 American Heart Association Guidelines update bronchopulmonary dysplasia: a meta-analysis. Pediatrics. for cardiopulmonary resuscitation and emergency cardiovascular 2013;132(5):e1351–e1360 care (reprint). Pediatrics. 2015;136(Suppl 2):S196–S218 12. Schmölzer GM, Kumar M, Pichler G, Aziz K, O’Reilly M, Cheung 29. Dawson JA, Schmolzer GM, Kamlin CO, et al. Oxygenation with T- PY. Non-invasive versus invasive respiratory support in preterm piece versus self-inflating bag for ventilation of extremely preterm infants at birth: systematic review and meta-analysis. BMJ. infants at birth: a randomized controlled trial. J Pediatr. 2013;347:f5980 2011;158(6):912–918 13. Jobe AH, Hillman N, Polglase G, Kramer BW, Kallapur S, Pillow J. 30. Szyld E, Aguilar A, Musante GA, et al. Comparison of devices for Injury and inflammation from resuscitation of the preterm infant. newborn ventilation in the delivery room. J Pediatr. Neonatology. 2008;94(3):190–196 2014;165(2):234–239 14. Vento M, Cheung PY, Aguar M. The first golden minutes of the 31. Thakur A, Saluja S, Modi M, et al. T-piece or self inflating bag for extremely-low-gestational-age neonate: a gentle approach. positive pressure ventilation during delivery room resuscitation: an Neonatology. 2009;95(4):286–298 RCT. Resuscitation. 2015;90:21–24 15. Stoll BJ, Hansen NI, Bell EF, et al; Eunice Kennedy Shriver National 32. Guinsburg R, de Almeida MFB, de Castro JS, et al. T-piece versus Institute of Child Health and Human Development Neonatal self-inflating bag ventilation in preterm neonates at birth. Arch Dis Research Network. Trends in care practices, morbidity, and Child Fetal Neonatal Ed. 2018;103(1):F49–F55 mortality of extremely preterm neonates, 1993-2012. JAMA. 33. Mian Q, Cheung PY, O’Reilly M, Barton SK, Polglase GR, – 2015;314(10):1039 1051 Schmölzer GM. Impact of delivered tidal volume on the occurrence 16. LeVan JM, Wyckoff MH, Ahn C, et al. Change in care among of intraventricular haemorrhage in preterm infants during positive nonenrolled patients during and after a randomized trial. Pediatrics. pressure ventilation in the delivery room. Arch Dis Child Fetal 2013;132(4):e960–e970 Neonatal Ed. 2019;104(1):F57–F62 17. Kakkilaya V, Jubran I, Mashruwala V, et al. Quality improvement 34. Hinder M, McEwan A, Drevhammer T, Donaldson S, Tracy MB. T- project to decrease delivery room intubations in preterm infants. piece resuscitators: how do they compare? Arch Dis Child Fetal Pediatrics. 2019;143(2):e20180201 Neonatal Ed. 2019;104(2):F122–F127 18. Palme C, Nyström B, Tunell R. An evaluation of the efficiency of face 35. Schmölzer GM, Kumar M, Aziz K, et al. Sustained inflation versus masks in the resuscitation of newborn infants. Lancet. positive pressure ventilation at birth: a systematic review and meta- 1985;1(8422):207–210 analysis. Arch Dis Child Fetal Neonatal Ed. 2015;100(4):F361–F368

e496 NeoReviews Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 36. Kirpalani H, Ratcliffe SJ, Keszler M, et al; SAIL Site Investigators. 50. Wung JT, Driscoll JM Jr, Epstein RA, Hyman AI. A new device for Effect of sustained inflations vs intermittent positive pressure CPAP by nasal route. Crit Care Med. 1975;3(2):76–78 ventilation on bronchopulmonary dysplasia or death among 51. Pillow JJ, Travadi JN. Bubble CPAP: is the noise important? An extremely preterm infants: The SAIL Randomized Clinical Trial. in vitro study. Pediatr Res. 2005;57(6):826–830 JAMA. 2019;321(12):1165–1175 52. Lee KS, Dunn MS, Fenwick M, Shennan AT. A comparison of 37. Poulton DA, Schmölzer GM, Morley CJ, Davis PG. Assessment of underwater bubble continuous positive airway pressure with chest rise during mask ventilation of preterm infants in the delivery ventilator-derived continuous positive airway pressure in – room. Resuscitation. 2011;82(2):175 179 premature neonates ready for extubation. Biol Neonate. 38. Finer NN, Rich W, Wang C, Leone T. Airway obstruction during 1998;73(2):69–75 mask ventilation of very low birth weight infants during neonatal 53. Morley C. Continuous distending pressure. Arch Dis Child Fetal – resuscitation. Pediatrics. 2009;123(3):865 869 Neonatal Ed. 1999;81(2):F152–F156 39. Kong JY, Rich W, Finer NN, Leone TA. Quantitative end-tidal carbon 54. Hishikawa K, Fujinaga H, Ito Y. Increased dead space in face mask dioxide monitoring in the delivery room: a randomized controlled continuous positive airway pressure in neonates. Pediatr Pulmonol. – trial. J Pediatr. 2013;163(1):104 108 2017;52(1):107–111 ’ 40. Murthy V, O Rourke-Potocki A, Dattani N, et al. End tidal carbon 55. Kattwinkel J, Fleming D, Cha CC, Fanaroff AA, Klaus MH. A device dioxide levels during the resuscitation of prematurely born infants. for administration of continuous positive airway pressure by the – Early Hum Dev. 2012;88(10):783 787 nasal route. Pediatrics. 1973;52(1):131–134 ’ 41. van Os S, Cheung PY,Pichler G, Aziz K, O Reilly M, Schmölzer GM. 56. De Paoli AG, Morley CJ, Davis PG, Lau R, Hingeley E. In vitro Exhaled carbon dioxide can be used to guide respiratory support in comparison of nasal continuous positive airway pressure devices for – the delivery room. Acta Paediatr. 2014;103(8):796 806 neonates. Arch Dis Child Fetal Neonatal Ed. 2002;87(1):F42–F45 42. Chalak LF, Barber CA, Hynan L, Garcia D, Christie L, Wyckoff MH. 57. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure End-tidal CO2 detection of an audible heart rate during neonatal sources for administration of nasal continuous positive airway cardiopulmonary resuscitation after asystole in asphyxiated piglets. pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. – Pediatr Res. 2011;69(5 Pt 1):401 405 2008; (1):CD002977 43. Wood FE, Morley CJ, Dawson JA, et al. Improved techniques reduce 58. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; face mask leak during simulated neonatal resuscitation: study 2. COIN Trial Investigators. Nasal CPAP or intubation at birth for very – Arch Dis Child Fetal Neonatal Ed. 2008;93(3):F230 F234 preterm infants. N Engl J Med. 2008;358(7):700–708 44. Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK. 59. Courtney SE, Pyon KH, Saslow JG, Arnold GK, Pandit PB, Habib Treatment of the idiopathic respiratory-distress syndrome with RH. Lung recruitment and breathing pattern during variable versus continuous positive airway pressure. N Engl J Med. continuous flow nasal continuous positive airway pressure in – 1971;284(24):1333 1340 premature infants: an evaluation of three devices. Pediatrics. 45. Saunders RA, Milner AD, Hopkin IE. The effects of continuous 2001;107(2):304–308 positive airway pressure on lung mechanics and lung volumes in 60. Frizzola M, Miller TL, Rodriguez ME, et al. High-flow nasal cannula: – the neonate. Biol Neonate. 1976;29(3-4):178 186 impact on oxygenation and ventilation in an acute lung injury 46. Locke R, Greenspan JS, Shaffer TH, Rubenstein SD, Wolfson MR. model. Pediatr Pulmonol. 2011;46(1):67–74 Effect of nasal CPAP on thoracoabdominal motion in neonates with 61. Locke RG, Wolfson MR, Shaffer TH, Rubenstein SD, Greenspan JS. fi – respiratory insuf ciency. Pediatr Pulmonol. 1991;11(3):259 264 Inadvertent administration of positive end-distending pressure 47. Miller MJ, Carlo WA, Martin RJ. Continuous positive airway during nasal cannula flow. Pediatrics. 1993;91(1):135–138 pressure selectively reduces obstructive apnea in preterm infants. 62. Sivieri EM, Gerdes JS, Abbasi S. Effect of HFNC flow rate, cannula – J Pediatr. 1985;106(1):91 94 size, and nares diameter on generated airway pressures: an in vitro 48. Faridy EE. Effect of distension on release of surfactant in excised study. Pediatr Pulmonol. 2013;48(5):506–514 ’ – dogs lungs. Respir Physiol. 1976;27(1):99 114 63. Reynolds P, Leontiadi S, Lawson T, Otunla T, Ejiwumi O, Holland 49. Weiner GMZJ, Kattwinkel J, eds. Textbook of Neonatal Resuscitation. N. Stabilisation of premature infants in the delivery room with 7th ed. Itasca, IL: American Academy of Pediatrics and American nasal high flow. Arch Dis Child Fetal Neonatal Ed. Heart Association; 2016 2016;101(4):F284–F287

Vol. 20 No. 9 SEPTEMBER 2019 e497 Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 NeoReviews Quiz Individual CME quizzes are available via the blue CME link in the Table of Contents of any issue. To learn how to claim MOC points, go to: http://www.aappublications.org/content/moc-credit.

1. The team is preparing for the delivery of an infant at 25 weeks’ gestational age. Which of NOTE: Learners can take the following statements regarding anticipation of respiratory management for this infant NeoReviews quizzes and is correct? claim credit online only A. With optimal care including antenatal steroids and cesarean delivery, less than 20% at: http://Neoreviews.org. of infants at this gestational age will require positive pressure ventilation in the To successfully complete delivery room. 2019 NeoReviews articles B. Brief exposure to large tidal volume breaths, even immediately after birth, can for AMA PRA Category 1 fl initiate an in ammatory cascade that alters lung architecture and contributes to CreditTM, learners must the development of bronchopulmonary dysplasia. demonstrate a minimum C. Even if it is not absolutely needed, the delivery of 10 to 20 carefully adjusted performance level of 60% positive pressure ventilation breaths in a prophylactic fashion for all newborns in or higher on this this circumstance will lead to decreased need for intubation and reduced incidence assessment, which of respiratory distress syndrome and bronchopulmonary dysplasia. measures achievement of D. Continuous positive airway pressure should be avoided until stabilization has the educational purpose progressed in the NICU to avoid pneumothorax. and/or objectives of this fi E. The main factor that will drive respiratory management in the rst few minutes, activity. If you score less particularly in the decisions surrounding positive pressure ventilation, is oxygen than 60% on the saturation measurement. assessment, you will be 2. A male infant born at 26 weeks’ gestational age is handed to the pediatrics team after 60 given additional seconds of delayed cord clamping. The infant has spontaneous respirations at first, but opportunities to answer proceeds to have apnea and bradycardia. The patient is given positive pressure ventilation. questions until an overall Which of the following statements regarding the interface for delivering positive pressure 60% or greater score is ventilation is correct? achieved. fi A. The rst-line treatment for this patient should be endotracheal intubation. This journal-based CME B. Nasal prongs have proven more effective than face mask for positive pressure activity is available delivery in this population. through Dec. 31, 2021, C. Triangular face masks have consistently been shown to have less air leak than however, credit will be circular masks in this population. recorded in the year in D. For face masks, the correct size should be determined by placing the bottom of the which the learner mask on the tip of the chin to cover the mouth and nose, but with the top of the completes the quiz. mask not reaching the eyes. E. The optimal “hold” of a face mask for preterm infants is to place in the correct position on the face, but actually not to hold it in place and let it lie there gently. 3. A female infant born at 27 weeks’ gestational age is delivered vaginally and is handed to the pediatrics team after 60 seconds of delayed cord clamping. The infant has spontaneous respirations before cord clamping. At the radiant warmer, the infant is gasping and is 2019 NeoReviews now is determined to have inadequate respirations. The team initiates positive pressure approved for a total of 10 ventilation. Which of the following parameters for initial support for this patient is most Maintenance of appropriate? Certification (MOC) Part 2 credits by the American A. Inflation pressure of 30 cm H2O. B. No positive end-expiratory pressure for the first few minutes. Board of Pediatrics C. A rate of 40 to 60 breaths/min. through the ABP MOC D. Oxygen concentration of 60%. Portfolio Program. fi E. Sustained inspiratory time of 10 seconds. Complete the rst 5 issues or a total of 10 quizzes of journal CME credits, achieve a 60% passing score on each, and start claiming MOC credits as early as May 2019.

e498 NeoReviews Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 4. The pediatrics team is preparing for the delivery of an infant at 27 weeks’ gestational age for worsening preeclampsia in the mother. Several choices for delivering positive pressure ventilation are available to the team. Which of the following are advantages of a T-piece resuscitator over a self-inflating bag? A. The ability to accurately detect tidal volumes. B. Several studies showing improved neurodevelopmental outcomes at 2 years of age. C. Easier to deliver controlled positive pressure ventilation and continuous positive airway pressure. D. Safeguard mechanism to ensure that an exact positive end-expiratory pressure never exceeds 5 mm H2O. E. Capacity to work without a gas source. 5. A newborn infant delivered at 28 weeks’ gestational age is receiving positive pressure ventilation by T-piece and mask at 2 minutes of age for apnea and heart rate of 60 beats/ min. Which of the following is the best indicator of the effectiveness of positive pressure ventilation? A. A rising heart rate. B. Increasing pink color of the extremities. C. Manometry pressures indicating a peak inspiratory pressure greater than 20 cm H2O. D. Oxygen saturation reading greater than 90%. E. Consistent positive end-expiratory pressure reading of 5 cm H2O.

Vol. 20 No. 9 SEPTEMBER 2019 e499 Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 Noninvasive Ventilation in the Delivery Room for the Preterm Infant Heather Weydig, Noorjahan Ali and Venkatakrishna Kakkilaya NeoReviews 2019;20;e489 DOI: 10.1542/neo.20-9-e489

Updated Information & including high resolution figures, can be found at: Services http://neoreviews.aappublications.org/content/20/9/e489 References This article cites 59 articles, 20 of which you can access for free at: http://neoreviews.aappublications.org/content/20/9/e489.full#ref-list- 1 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Pediatric Drug Labeling Update http://classic.neoreviews.aappublications.org/cgi/collection/pediatric _drug_labeling_update Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: https://shop.aap.org/licensing-permissions/ Reprints Information about ordering reprints can be found online: http://classic.neoreviews.aappublications.org/content/reprints

Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019 Noninvasive Ventilation in the Delivery Room for the Preterm Infant Heather Weydig, Noorjahan Ali and Venkatakrishna Kakkilaya NeoReviews 2019;20;e489 DOI: 10.1542/neo.20-9-e489

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://neoreviews.aappublications.org/content/20/9/e489

Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2000. Neoreviews is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Online ISSN: 1526-9906.

Downloaded from http://neoreviews.aappublications.org/ at Nicaragua:AAP Sponsored on September 4, 2019