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Using exhaled CO2 to guide initial respiratory support at birth: a randomised controlled trial
  1. Ashley Y Ngan1,
  2. Po-Yin Cheung1,2,
  3. Ann Hudson-Mason1,
  4. Megan O’Reilly1,2,
  5. Sylvia van Os1,
  6. Manoj Kumar2,
  7. Khalid Aziz1,2,
  8. Georg M Schmölzer1,2
  1. 1Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
  2. 2Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
  1. Correspondence to Dr Georg M Schmölzer, Centre for theStudies of Asphyxia and Resuscitation, Neonatal ResearchUnit, Royal Alexandra Hospital, Edmonton, Alberta, T5H 3V9, Canada; georg.schmoelzer{at}


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.

  • Infant
  • Newborn
  • Delivery room
  • Neonatal Resuscitation
  • Sustained Inflation, Positive Pressure Ventilation
  • Respiratory Function Tests
  • ExHaled Carbon Dioxide

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  • Contributors GMS and AYN had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conception and design: GMS, KA, SvO, MOR, P-YC, MK. Collection and assembly of data: AYN, GMS, SvO, KA, AH-M, MOR, P-YC. Analysis and interpretation of the data: AYN, GMS, SvO, KA, AH-M, MOR, P-YC. Drafting of the article: AYN, GMS, KA, MOR, P-YC, SvO, AH-M. Critical revision of the article for important intellectual content: GMS, KA, MOR, AH-M, P-YC, SvO, AYN, MK. Final approval of the article: GMS, AYN, KA, MOR, P-YC, SvO, AH-M, MK.

  • Funding The study was supported by a Seed Funding Grant of the Department ofPediatrics, University of Alberta, Edmonton, Canada, and a Canadian RespiratoryHealth Professionals (CRHP) Grant, The Lung Association, Canada. MOR was supported by a Fellowship of the Molly Towell PerinatalFoundation. GMS is a recipient of the Heart and Stroke Foundation/University ofAlberta Professorship of Neonatal Resuscitation and a Heart and StrokeScholarship. No financial relationships with any organizations that might have aninterest in the submitted work in the previous 3 years; no other relationshipsor activities that could appear to have influenced the submitted work.

  • Competing interests None declared.

  • Patient consent Parental consent obtained.

  • Ethics approval The RAH Research Committee and Health Ethics Research Board, University of Alberta (Pro00034524).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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