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

Arch Dis Child Fetal Neonatal Ed. 2017 Nov;102(6):F525-F531. doi: 10.1136/archdischild-2016-312286. Epub 2017 Jun 8.


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.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Bronchopulmonary Dysplasia / epidemiology*
  • Bronchopulmonary Dysplasia / prevention & control
  • Carbon Dioxide / metabolism*
  • Female
  • Humans
  • Infant, Newborn
  • Insufflation / adverse effects
  • Insufflation / methods*
  • Male
  • Positive-Pressure Respiration / adverse effects
  • Positive-Pressure Respiration / methods*
  • Respiratory Function Tests


  • Carbon Dioxide

Associated data