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Original article
Mask ventilation of preterm infants in the delivery room
  1. Jonathan Kaufman1,
  2. Georg M Schmölzer1,2,3,4,6,
  3. C Omar F Kamlin1,3,5,
  4. Peter G Davis1,3,5
  1. 1Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
  2. 2Department of Newborn Medicine, Royal Alexandra Hospital, Edmonton, Canada
  3. 3Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia
  4. 4Division of Neonatology, Department of Paediatrics, Medical University Graz, Graz, Austria
  5. 5Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
  6. 6Department of Pediatrics, University of Alberta, Edmonton, Canada
  1. Correspondence to Dr Georg M Schmölzer, Department of Newborn Medicine, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, Alberta, Canada T5H 3V9; georg.schmoelzer{at}me.com

Abstract

Objective To measure tidal volumes (VT) and describe the interactions between spontaneous breaths and positive pressure ventilation (PPV) inflations during stabilisation of preterm infants in the delivery room (DR). We used a respiratory function monitor (RFM) to evaluate the first 5 min of mask respiratory support provided to preterm infants.

Study design An observational study of infants <32 weeks gestation, born in a single tertiary perinatal centre receiving mask PPV in the DR. PPV was delivered with a round silicone facemask connected to a T-piece device and RFM. The RFM display was not visible to the resuscitator. Respiratory function parameters in the first 5 min after birth were analysed by breath-type (inflations, assisted inflations, spontaneous breaths between PPV, and breaths during continuous positive airway pressure (CPAP)). Parameters measured included VT, peak inspiratory pressure, peak end expiratory pressure and mask leak.

Results A total of 2605 inflations and breaths from 29 subjects were analysed. Substantial leak was observed during all four breath types with median leaks ranging from 24% to 59%. Median tidal volumes were greater during inflations (8.3 ml/kg) and assisted inflations (9.3 ml/kg) than spontaneous breaths between PPV (3.2 ml/kg) and breaths during CPAP (3.3 ml/kg).

Conclusions Facemask leak is large during resuscitation of preterm infants using round silicone masks. Tidal volumes delivered during PPV inflations are much higher than those generated during spontaneous breathing by an infant on CPAP.

  • Neonatology
  • Resuscitation

https://doi.org/10.1136/archdischild-2012-303313

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    What is already known on this topic

    • Mask leak and airway obstruction are common impediments to effective mask ventilation.

    • A respiratory function monitor displays mask leak, and may be used to achieve a target tidal volume during resuscitation.

    What this study adds

    • During mask ventilation, mask leak and tidal volume delivery are variable.

    • Tidal volumes during mask ventilation are significantly higher than during spontaneous breaths.

    • A respiratory function monitor has the potential to identify adverse events during mask ventilation.

    Introduction

    Approximately 10% of newborns require some assistance to establish regular breathing after birth, with 1% requiring extensive resuscitation.1 Stabilisation of newly born preterm infants often involves supplementing an infant's spontaneous breathing efforts with positive pressure ventilation (PPV). Current resuscitation guidelines recommend PPV in infants who have inadequate breathing or bradycardia.2 Obstacles to aerating the lungs of preterm infants include poor respiratory drive, weak muscles, a highly compliant chest wall, surfactant deficiency and impaired lung liquid clearance.3 ,4

    Assisted ventilation aims to establish a functional residual capacity (FRC) and deliver appropriate tidal volume (VT) to facilitate gas exchange.5 ,6 The effectiveness of PPV delivery may be compromised by mask leak, flow obstruction or inappropriate airway pressures, and may go unrecognised using standard clinical assessment of ‘effective ventilation’ (observing chest rise, improvement in spontaneous breathing, and an increase in heart rate).7–9 In addition, an infant's spontaneous respiratory efforts have been found to influence tidal volumes during resuscitation with PPV.10

    A respiratory function monitor (RFM) can assist the operator during resuscitation by providing objective data on flow of gas, VT, pressure, mask leak and the interaction with spontaneous breaths taken by the infant.11 This may, in turn, allow the resuscitator to adjust their technique in order to reduce leak, target a desired VT and potentially ‘synchronise’ inflations with the infant's breathing. However, at present, this equipment is not commonly available, and data are limited to research studies. Preliminary data suggests that RFM may reduce mask leak and decrease the rate of excessive VT during mask resuscitation of preterm infants.12 ,13

    We have previously described the ventilation and spontaneous breathing of babies with congenital diaphragmatic hernia in the delivery room (DR).14 Using data collected from the masked arm of a randomised trial of RFM in the DR,12 this study describes what happens when RFM data is not available to assist clinicians during the stabilisation of spontaneously breathing preterm infants.

    We aimed to describe respiratory function parameters of the spontaneously breathing preterm infant receiving PPV and continuous positive airway pressure (CPAP) support during the first 5 min after birth in the DR.

    Methods

    Patients and setting

    The Royal Women's Hospital, Melbourne, Australia, is a tertiary perinatal centre with approximately 6500 deliveries each year. Infants previously enrolled in a randomised control trial (RCT) were eligible for inclusion. The RCT compared clinical assessment (RFM masked) versus clinical assessment and the additional use of an RFM (RFM visible) during mask PPV in preterm infants <32 weeks gestation.12 The trial was approved by The Royal Women's Hospital Research and Ethics Committees and was registered with Australian and New Zealand Clinical Trials Registry ACTRN12608000357358, and was conducted between November 2008 and January 2010. Infants in the RCT were excluded if there was uncertainty about their gestational age or if they had a congenital abnormality that might adversely affect their breathing. The study was approved by The Royal Women's Hospital Research and Ethics Committees, and parental consent to use the recordings was obtained.

    This report only includes infants in the RFM masked group. In the original report, the analysis was limited to the first 40 inflations, whereas in the present study, we set out to analyse both spontaneous breaths and PPV inflations in the first 5 min from birth. Thus, it provides an insight into how clinicians ordinarily manage infants with varying levels of respiratory effort during transition after birth, and how PPV inflations delivered by clinicians compare with the spontaneous breaths taken by infants.

    Ventilation device and facemask

    PPV was delivered with a size 00 round silicone facemask (Laerdal, Stavanger, Norway) connected to a T-piece device (Neopuff Infant Resuscitator, Fisher & Paykel Healthcare, Auckland, New Zealand), a continuous flow, peak pressure-limited device with a manometer and positive end expiratory pressure (PEEP) valve. Resuscitation commenced with room air, peak inflation pressure (PIP) 30 cm H2O and PEEP 5 cm H2O.

    Respiratory function monitoring

    Gas flow towards and away from the infant was measured using a hot-wire anemometer flow sensor (Florian Respiratory Function Monitor, Acutronic Medical Systems AG, Zug, Switzerland) placed between the ventilation device and the facemask. The dead space of the flow sensor is 1 ml. This signal was integrated to derive inspiratory and expiratory VT. Airway pressure was measured proximal to the facemask. The measured signals were recorded and digitised using a neonatal respiratory physiologic recording program (Spectra, Grove Medical, Hampton, UK).

    Data collection and analysis

    All inflations delivered to, and spontaneous breaths taken by, each infant in the first 5 min after birth were manually analysed breath by breath. Breath types were identified by analysis of pressure, flow and tidal volume waveforms during PPV. We used video recording to resolve any ambiguity relating to the timing of inflations.

    Breaths were divided into three categories as described by te Pas et al15: inflations (figure 1A), assisted inflations (spontaneous breaths coinciding with an inflation) (figure 1B), and spontaneous breaths between PPV inflations (figure 1C). In addition, all spontaneous breaths taken during mask CPAP (figure 1D) were included. For data analysis, a spontaneous breath between PPV inflations was defined as a single breath appearing between two PPV inflations (figure 1C). More than one consecutive breath was defined as spontaneous breaths during mask CPAP (figure 1D). The original RCT included only infants receiving mask PPV, the analysis was limited to the first 40 inflations, did not differentiate between inflations and assisted inflations (figure 1A,B) during PPV,12 and did not include assessment of spontaneous breaths between PPV inflations or during CPAP (figure 1C,D).

    Figure 1
    Figure 1

    (online supplement). Positive pressure ventilation (PPV) and continuous positive airway pressure (CPAP) in a 31-week gestation preterm infant with a birth weight of 1000 g. (A): Manual inflations during PPV (inflations). Airway pressure rises concurrently with inspiratory gas flow curve. During expiration, gas flow and airway pressure waveforms return to baseline. (B): A spontaneous breath coincides with a manual inflation during PPV (assisted inflations). Two inspiratory flow wave curves occur resulting in one tidal volume wave during the assisted inflation. (C): Spontaneous breaths between PPV. Between two manual PPV inflations a spontaneous breath occurs, which is characterised by an inspiratory and expiratory flow between positive pressure inflations. (D): Breaths during CPAP. The spontaneous breath was characterised by an inspiratory and expiratory flow while on mask CPAP.

    PIP, PEEP, expired tidal volume (VTe), inflation time and respiratory rate (RR) were measured. Mask leak was calculated as a percentage of the inspired VT using a previous published calculation ((inspiratory VT−VTe)÷(inspiratory VT)×100).16 Airway obstruction was defined as zero inspiratory and expiratory flow and no VT display.11 ,17 VT was corrected for body temperature, pressure and water vapour saturation using a standardised equation.18

    Statistics

    Results are presented as mean (SD) for normally distributed continuous variables and median (IQR) when the distribution was skewed. For all respiratory parameters, the median value for each infant was calculated, and then the overall mean or median of those medians calculated. Tidal volumes of the four different types of breaths were compared using repeated measures analysis of variance (ANOVA) with Bonferroni multiple comparison post-test analysis. Statistical analyses were performed with Stata (Intercooled 10, Statacorp Texas, USA), and a p value of <0.05 was considered statistically significant. The sample size of this descriptive study was limited to the number of control infants recruited to the original RCT.

    Results

    In the original RCT, a total of 100 infants (54 RFM visible and 46 RFM masked) were enrolled, and 26 infants in the RFM visible and 23 infants in the RFM masked group had the first 40 PPV inflations analysed.12 In the current study, all PPV inflations provided, and spontaneous breaths taken during CPAP in the first 5 min after birth from infants in the RFM masked group, were eligible for inclusion. In this study, we describe respiratory function parameters in 29 infants (including an additional six infants who were excluded from the original RCT as they received less than 40 inflations). Fifteen of 46 enrolled infants were excluded (8=no respiratory support required, 6=recording system failure, 1=no consent) from further analysis.

    A total of 3864 PPV inflations and spontaneous breaths were analysed; a total of 1259 were unable to be interpreted and excluded. Overall 2605 PPV inflations and spontaneous breaths were included in the current analysis; 1538 (59%) inflations, 283 (11%) assisted inflations, 64 (3%) spontaneous breaths between PPV, and 720 (27%) breaths during CPAP. The median number (range) of PPV inflations and spontaneous breaths per infant analysed were 60 (13–235) and 70 (22–177), respectively.

    Infants had a mean (SD) birth weight of 1008 (327) g, and gestational age of 27 (2) weeks. The demographics are presented in table 1.

    View this table:
    Table 1

    Infant demographics

    Respiratory parameters

    The delivered airway pressures (PEEP, PIP), inspiratory time, and RR are presented in table 2. The delivered PIPs for inflations and assisted inflations were not significantly different. PEEP was lowest during spontaneous breaths between PPV (table 2). All breath types had similar inspiration times.

    View this table:
    Table 2

    Respiratory parameters for all four groups

    Mask leak

    Substantial leak was observed during all four breath types with median leaks ranging from 24% to 59%, with a wide variability in the measured mask leak (table 2). Pairwise comparisons (inflations vs each of the other types) showed no significant difference in measured leak (table 2).

    Tidal volume delivery

    Overall, the delivered tidal volumes were variable, and were greatest during inflations and assisted inflations (table 2, figure 2). Pairwise comparisons showed tidal volumes during spontaneous breaths (breaths between PPV and breaths while on CPAP) were significantly reduced compared with those delivered during inflations (table 2).

    Figure 2
    Figure 2

    Expired tidal volume in ml/kg for inflations, assisted inflations, spontaneous breaths between positive pressure ventilation, and breaths during continuous positive airway pressure. Box plots show median (solid bar), IQR (margins of the box) and 95% CI.

    Median (IQR) VT of spontaneous breaths for infants maintained on CPAP compared with those intubated in the DR was similar 3.5 (3.1–5.5) ml/kg vs 2.9 (1.8–6.0) m/kg (p=0.3446), respectively.

    Airway obstruction

    In 10% of infants (3/29), we observed obstructed inflations during mask PPV; two, eight and 13 obstructed inflations were observed for each infant. An example of airway obstruction is shown in figure 3.

    Figure 3
    Figure 3

    (online supplement) Airway obstruction during mask positive pressure ventilation. During episodes of airway obstructions, the set airway pressures (peak inflation pressure and positive end expiratory pressure) are achieved, however, no gas flow or tidal volume waves are observed.

    Discussion

    To our knowledge, this is the first study describing in detail, the first 5 min of mask respiratory support provided to preterm infants born within less than 32 weeks gestation using a RFM. Many preterm infants breathe and cry in the DR,19 and for these infants ‘stabilisation’ often involves using a facemask to apply PEEP/CPAP pressure with intermittent PPV. Our observations highlight the wide range of tidal volumes delivered and large facemask leaks with both PPV inflations and non-assisted breaths. As these data were masked from the clinical team, we believe these results are typical of what happens in our DRs.

    Previous studies have reported spontaneous breathing patterns in preterm babies without support15 and on CPAP,20 but this is the first that describes respiratory function in the DR when both PPV and mask CPAP support are provided to stabilise spontaneously breathing infants in the DR. To our knowledge, the interaction of spontaneous breaths with PPV inflations has not previously been reported.

    Our original RCT focused on infants who received substantial numbers of assisted inflations and reported only the first 40 from each infant.12 This report aimed to look more closely at all eligible infants in the ‘monitor masked group’ and for a longer period of time (5 min) during transition in the DR. A total of 2605 spontaneous breaths and PPV inflations were analysed, compared with 920 PPV inflations reported in the RFM masked group of the RCT.12

    We observed significantly higher delivered tidal volumes with manually applied positive pressure inflations (inflations and assisted inflations) than for the infant's spontaneous breaths (between inflations and during mask CPAP). This is consistent with other studies suggesting that babies who breathe for themselves often achieve lower tidal volumes with less breath-to-breath variability.21 Median (IQR) tidal volumes were 9.0 (6.1–10.8) ml/kg during inflations, and 9.3 (4.5–12.9) ml/kg during assisted inflations (figure 2), which were higher than the masked group published from our original RCT.12 We speculate that the longer duration of recording, the greater number of analysed inflations, and perhaps a greater proportion of ‘assisted inflations’ may have contributed to this. The variability of tidal volumes during PPV and larger tidal volumes delivered when an inflation coincides with a spontaneous breath (assisted inflations) has been reported in previous studies.10 ,14

    Inflations with a VT exceeding 10 ml/kg have the potential to damage the vulnerable preterm lung.22 ,23 However, the optimal initial inflation pressure during PPV in preterm infants is unknown. Recent resuscitation guidelines suggest an initial PIP of 20 cm H2O to prevent overinflation and potential volutrauma. The guidelines suggest that 30–40 cm H2O may be required in some apneic term babies.2 The initial PIP used in the current study of 30 cm H2O could have contributed to higher VT delivery.

    Airway obstruction is a common problem during facemask PPV (figure 3).17 ,24 ,25 Finer et al24 reported airway obstruction in 75% of infants receiving facemask ventilation using a Pedi-Cap in the DR. Schmölzer et al17 reported that 25% of infants experience severe airway obstruction during the first 2 min of mask PPV. In the current study, we observed complete airway obstruction in 10% of infants. Total airway obstruction was more likely to appear in the first 2 min of facemask PPV, which is similar to previously published studies.17 ,24

    Limitations

    Obtaining physiological recordings in the DR is difficult due to timing and equipment needs.15 ,20 The number of breaths analysed in this study was therefore relatively small. However, we describe some potential pitfalls when providing mask ventilation to preterm infants in the DR. Mask leak is potentially overestimated during FRC establishment, as some gas is retained in the lungs. Although a continuous flow device, like a T-piece, may be expected to produce a larger leak, a recent RCT by Dawson et al26 reported no difference in mask leak between a Neopuff T-Piece and a Laerdal self-inflating bag.

    For infants spontaneously breathing during mask CPAP it was difficult to obtain long periods of recorded breaths because of infant movement, variable leaks and presence of secretions. Nevertheless, the measurements made in this study were consistent with those reported by others and we believe are representative of most preterm infants in the first minutes of life. Another limitation may be the interpretation of the measurements taken during spontaneous breathing as waveforms of small tidal volume breaths may be interpreted as large leak, or mistakenly classified as complete obstruction. This is because complete airflow obstruction is indistinguishable from apnoea using the RFM waveforms in isolation. Video recordings of the infants breathing assists with this process, and for all the waveforms analysed in this study, we were able to confirm timing of inflations using video.

    Conclusion

    Our observations in the DR confirm the presence of large facemask leaks and variability of tidal volume delivery during mask ventilation of preterm infants when operators rely on clinical signs to guide support. The potential of RFM to detect and manage problems associated with mask ventilation in the DR needs to be assessed in large clinical trials.

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    Footnotes

    • Author note Using data collected during the masked arm of the randomised trial ‘Respiratory function monitor guidance of mask ventilation in the delivery room: a feasibility study’. J Pediatr 2012;160(3):377–81, this study aims to describe in detail what happens during the stabilisation of the spontaneously breathing preterm infant receiving mask ventilation in the first 5 min after birth in the delivery room. This report includes only infants in the masked arm of the randomised trial, and more closely examines how clinicians manage infants with varying levels of respiratory effort during transition after birth, and how mask inflations interact with spontaneous breaths taken by infants. The original study compared only the first 40 inflations in each infant. This manuscript examined all spontaneous breaths and manual inflations over the first 5 min after birth in all eligible infants randomised into the masked group. We believe this paper complements the already published randomised trial and provides insight into how preterm infants transitioning in the delivery room are managed, and the interaction of manual inflations with the infant's own respiratory efforts.

    • Contributors Conception and design of study: JK, GMS, COFK and PGD. Data acquisition: GMS, COFK and PGD. Data analysis: JK, GMS, COFK, PGD. Data interpretation: JK, GMS, COFK and PGD. Manuscript drafting: JK, GMS, COFK and PGD. Final approval of manuscript: JK, GMS, COFK and PGD.

    • Competing interests GMS and COFK were recipients of a Royal Women's Hospital Postgraduate Scholarship. PGD is supported by an Australian National Health and Medical Research Council Practitioner and Principal Research Fellowship, respectively. PGD holds an Australian National Health and Medical Research Council Program Grant No. 606789. First draft of manuscript written by Jonathan Kaufman.

    • Patient consent Obtained.

    • Ethics approval The Royal Women's Hospital Ethics Committees.

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