Delivery Room Management of Extremely Low Birth Weight Infants: Spontaneous Breathing or Intubation?

• Published in: Pediatrics (Evanston) 1999-05, Vol.103 (5), p.961-967
• Main Authors: Lindner, Wolfgang, Vossbeck, Sabine, Hummler, Helmut, Pohlandt, Frank
• Format: Article
• Language: English
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Artificial respiration; Biological and medical sciences; Birth weight; Birth weight, Low; Care and treatment; Cohort Studies; Delivery Rooms; Emergency and intensive respiratory care; Female; Health aspects; Humans; Infant mortality; Infant, Newborn; Infant, Very Low Birth Weight; Infants (Newborn); Intensive care medicine; Intensive Care Units, Neonatal; Intubation, Intratracheal - statistics & numerical data; Low birth weight; Mechanical ventilation; Medical sciences; Newborn infants; Pediatric respiratory diseases; Pediatrics; Positive-Pressure Respiration - statistics & numerical data; Practice Guidelines as Topic; Pregnancy; Respiratory Distress Syndrome, Newborn - epidemiology; Respiratory Distress Syndrome, Newborn - therapy; Respiratory insufficiency; Respiratory insufficiency in children; Retrospective Studies
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/peds.103.5.961

To study the effect of two different delivery room (DR) policies on the rate of endotracheal intubation and mechanical ventilation (EI/MV) and short term morbidity in extremely low birth weight infants (ELBWI; /=24 weeks). Retrospective cohort study of 123 inborn ELBWIs born in 1994 and in 1996. DR policies have changed. Until 1994, ELBWIs were intubated immediately after delivery when presenting the slightest signs of respiratory distress or asphyxia after initial resuscitation using a face mask and a handbag. During 1995, the guidelines for respiratory support were changed. In 1996, continuous (15 to 20 seconds), pressure controlled (20 to 25 cm H2O) inflation of the lungs using a nasal pharyngeal tube, followed by continuous positive airway pressure (CPAP; 4 to 6 cm H2O) was applied to all ELBWIs immediately after delivery to establish a functional residual capacity and perhaps to avoid EI/MV. In addition to the changes in respiratory support, the prevention of conductive and evaporative heat loss was improved in 1996. For analysis of morbidity and mortality, infants were matched for gestational age and birth weight. The rate of EI/MV in the DR decreased from 84% in 1994 to 40% in 1996. In 1996, 25% of the ELBWIs were never intubated (7% in 1994), but 35% of the ELBWIs needed secondary EI/MV, primarily because of respiratory distress syndrome (RDS). Initial ventilator settings, ventilator days, mortality, and morbidity were not different between ELBWIs with EI/MV in the DR and infants with secondary EI/MV attributable to RDS in the intensive care unit. ELBWIs with no EI/MV that was caused by RDS had a lower morbidity (ie, bronchopulmonary dysplasia, intraventricular hemorrhage >grade 2 and/or periventricular leukomalacia), mortality, and fewer hospital days (mean: 79 vs 105 days). The incidence of gastrointestinal adverse effects like feeding intolerance or necrotizing enterocolitis was not increased in 1996. PaCO2 was significantly higher at admission to the neonatal unit in ELBWIs with CPAP in 1996 (54 +/- 15 mm Hg, 7.2 +/- 2.0 kPa) compared with infants with EI/MV in 1994 (38 +/- 11 mm Hg, 5.1 +/- 1. 5 kPa. A total of 26% of spontaneously breathing infants had hypercapnia (PaCO2 >/=60 mm Hg [8.0 kPa]), compared with 7% of infants with EI/MV in 1994. Within the first few hours of life, PaCO2 decreased to 46 (32 to 57) mm Hg (6.1 [4.3 to 7.6] kPa) in never intubated ELBWIs (n = 17), but increased to 70 (57 to 81) mm Hg (9.3 [7.6 to 10.8] kPa)