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Supporting breathing of preterm infants at birth: a narrative review
  1. Tessa Martherus1,
  2. André Oberthuer2,
  3. Janneke Dekker1,
  4. Stuart B Hooper3,4,
  5. Erin V McGillick3,4,
  6. Angela Kribs2,
  7. Arjan B te Pas1
  1. 1 Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
  2. 2 Department of Neonatology, Children’s Hospital University of Cologne, Cologne, Germany
  3. 3 The Ritchie Centre, Hudson Institute for Medical Research, Clayton, Victoria, Australia
  4. 4 Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
  1. Correspondence to Tessa Martherus, Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands; t.martherus{at}


Most very preterm infants have difficulty aerating their lungs and require respiratory support at birth. Currently in clinical practice, non-invasive ventilation in the form of continuous positive airway pressure (CPAP) and positive pressure ventilation (PPV) is applied via facemask. As most very preterm infants breathe weakly and unnoticed at birth, PPV is often administered. PPV is, however, frequently ineffective due to pressure settings, mask leak and airway obstruction. Meanwhile, high positive inspiratory pressures and spontaneous breathing coinciding with inflations can generate high tidal volumes. Evidence from preclinical studies demonstrates that high tidal volumes can be injurious to the lungs and brains of premature newborns. To reduce the need for PPV in the delivery room, it should be considered to optimise spontaneous breathing with CPAP. CPAP is recommended in guidelines and commonly used in the delivery room after a period of PPV, but little data is available on the ideal CPAP strategy and CPAP delivering devices and interfaces used in the delivery room. This narrative review summarises the currently available evidence for why PPV can be inadequate at birth and what is known about different CPAP strategies, devices and interfaces used the delivery room.

  • neonatology
  • respiratory
  • physiology
  • resuscitation
  • technology

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  • Contributors TM was the executive researcher of this study. She performed the literature search, data collection and interpretation, writing and submitting of the report. AO was involved in designing the structure of the review and critically revised the content of the report. JD and SBH were involved in data interpretation and editing of the report. EVMc was involved in critical revision of the content and writing the report, the figures and tables. AK helped designing the structure of the review and was involved editing of the report. ABteP was the project leader as he designed the structure of the review, performed the literature search, performed the data interpretation, writing and editing of the report. All authors gave approval for the final version to be published and agree on the accountable for all aspects of the work. No honorarium, grant or other form of payment was given to anyone to produce the manuscript.

  • Funding This study was funded by Nederlandse Organisatie voor Wetenschappelijk Onderzoek (VIDI 91716428).

  • Competing interests None declared.

  • Patient consent Not required.

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