Delivery room management of extremely low birth weight infants: Spontaneous breathing or intubation?

W. Lindner et al., Delivery room management of extremely low birth weight infants: Spontaneous breathing or intubation?, PEDIATRICS, 103(5), 1999, pp. 961-967
Citations number
Categorie Soggetti
Pediatrics,"Medical Research General Topics
Journal title
ISSN journal
0031-4005 → ACNP
Year of publication
961 - 967
SICI code
Objective. 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; <100 0 g, greater than or equal to 24 weeks). Methods. Retrospective cohort study of 123 inborn ELBWIs born in 1994 and i n 1996, DR policies have changed. Until 1994, ELBWIs were intubated immedia tely after delivery when presenting the slightest signs of respiratory dist ress or asphyxia after initial resuscitation using a face mask and a handba g. During 1995, the guidelines for respiratory support were changed. In 199 6, continuous (15 to 20 seconds), pressure controlled (20 to 25 cm H2O) inf lation of the lungs using a nasal pharyngeal tube, followed by continuous p ositive airway pressure (CPAP; 4 to 6 cm H2O) was applied to all ELBWIs imm ediately after delivery to establish a functional residual capacity and per haps to avoid EI/MV. In addition to the changes in respiratory support, the prevention of conduc tive and evaporative heat loss was improved in 1996. For analysis of morbid ity and mortality, infants were matched for gestational age and birth weigh t. Results. The rate of EI/MV in the DR decreased from 84% in 1994 to 40% in 1 996. 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 dist ress syndrome (RDS). Initial ventilator settings, ventilator days, mortality, and morbidity were not different between ELBWIs with EI/MV in the DR and infants with seconda ry 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 dyspl asia, intraventricular hemorrhage >grade 2 and/or periventricular leukomala cia), mortality, and fewer hospital days (mean: 79 vs 105 days). The incide nce of gastrointestinal adverse effects like feeding intolerance or necroti zing 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 spo ntaneously breathing infants had hypercapnia (PaCO2 greater than or equal t o 60 mm Hg [8.0 kPa]), compared with 7% of infants with EI/MV in 1994, With in 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) in ELBWIs (n = 14) with RDS and se condary EI/MV (age 5.5 [1 to 44] hours). Conclusions. In our setting, the individualized intubation strategy in the DR restricted EI/MV to those ELBWIs who ultimately needed it, without incre asing morbidity or mortality in infants with secondary EI/MV attributable t o RDS. We speculate that an individualized intubation strategy of the ELBWI is superior to immediate intubation of all ELBWIs with slight signs of res piratory distress after birth.