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
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.