Using exhaled CO2 to guide initial respiratory support at birth: a randomised controlled trial

Abstract

Importance: A sustained inflation (SI) provided at birth might reduce bronchopulmonary dysplasia (BPD).

Objective: This study aims to examine whether an SI-guided exhaled carbon dioxide (ECO₂) compared with positive pressure ventilation (PPV) alone at birth decreases BPD.

Design: Randomised controlled trial. Infants were randomly allocated to either SI (SI group) or PPV (PPV group).

Participants: Participants of this study include infants between 23⁺⁰ and 32⁺⁶ weeks gestation with a need for PPV at birth.

Intervention: Infants randomised into the SI group received an initial SI with a peak inflation pressure (PIP) of 24 cmH₂O over 20 s. The second SI was guided by the amount of ECO₂. If ECO₂ was ≤20 mm Hg, a further SI of 20 s was delivered. If ECO₂ was >20 mm Hg the second SI was 10 s. Infants randomised into the PPV group received mask PPV with an initial PIP of 24 cmH₂O.

Primary outcomes: Reduction in BPD defined as the need for respiratory support or supplemental oxygen at corrected gestational age of 36 weeks.

Results: SI (n=76) and PPV (n=86) group had similar rates of BPD (23% vs 33%, p=0.090, not statistically significant). The duration of mechanical ventilation was significantly reduced with SI versus PPV (63 (10-246) hours versus 204 (17-562) hours, respectively (p=0.045)). No short-term harmful effects were identified from two SI lasting up to 40 s (eg, pneumothorax, intraventricular haemorrhage or patent ductus arteriosus).

Conclusion: Preterm infants <33 weeks gestation receiving SI at birth had lower duration of mechanical ventilation and similar incidence of BPD compared with PPV. Using ECO₂ to guide length of SI is feasible.

Trial registration number: NCT01739114; Results.

Keywords: Delivery room; ExHaled Carbon Dioxide; Infant; Neonatal Resuscitation; Newborn; Respiratory Function Tests; Sustained Inflation, Positive Pressure Ventilation.