Ventilation Management of Preterm Infants Consensus (2025)
Reviewed by Jennifer Cohen, MD
Reviewed on
Respiratory Management of Preterm infants <32 weeks in the Delivery Room
Date of Initial Publication: January 2021
Revision Date: May 2025
Contact Author: Jennifer Cohen
Contributing Authors: El Noh, Melissa Schmatz, Stephanie Ardell, Jennifer Hesler, John Chuo, Sarvin Ghavam, Kristen Nelson
Abstract
Aligned with goals of the division of Newborn Medicine, the CNBC strives to be in the best quartile of all VON key performance metrics, a mission that can be achieved through practice consensus and improvement. Chronic lung disease has been identified as a target outcome, but it has been demonstrated as a particularly challenging measure to improve, given that it’s cause is thought to have multiple contributing factors, both pre- and postnatally. The Network has chosen to focus on improvement of delivery room practices for infants <32 weeks as a means to improve long term outcomes, including CLD.
*All Guidelines are to be followed at all times in conjunction with NRP recommendations.
Consensus Goals
- Define practice recommendations:
- Noninvasive ventilation strategies at delivery for infants <32 weeks
- goals of optimizing PIP and PEEP
- Oxygen saturation parameters for the first 10 minutes after birth
- Timing of surfactant administration
- Define equipment recommendations:
- ECG monitoring
- T piece resuscitator
Background
Variation in delivery room practices and key performance outcomes across the Network have been identified by evaluating CHOP Newborn Care Network data submitted to the Vermont Oxford Network data repository and data collected during the CNBC Delivery Room Euthermia project. As a Network, combined CNBC data over the past 10 years shows CLD rates between 15-20%, which falls above the bottom (or best) quartile when comparted to all VON sites. Quality Index VON CLD Targets reached 26% of the time for better than 50% of VON sites and 12% of the time for better than 75% of VON sites. Our Network and Division goals are to have cumulative Network rates that consistently fall below the bottom quartile for VON.
Variation in practice across Network sites likely contributes to higher cumulative rates of CLD. Practice variation with delivery room ventilation practices for infants <32 weeks has also been identified during quality improvement initiatives evaluating delivery room practices.
Literature Review
| Title | Author | Level of Evidence | Primary Outcome | Results | Key Findings / Conclusions |
|---|---|---|---|---|---|
| Outcomes of oxygen saturation targeting during DR stabilization of preterm infants | Oei | Level 1 | Relationship between SpO2 at 5 min, death and intraventricula r hemorrhage (IVH) >grade 3 in infants exposed to lower (<0.3) and higher (>0.6) FiO2 | 8RCTs with pooled data showed decreased likelihood of reaching O2 sat of 80% if resuscitation was initiated with FiO2 <0.3 | Decreased cumulative risk of death for infants whose HR>100 and take shorter time to reach oxygen saturations of 80% |
| HR Monitoring in Babies | Anton | Level 3 | Accuracy in methods to detect HR in the NICU and DR | ECG and PO more accurate than palpation and auscultation | HR monitoring by ECG is more precise and acquired more quickly than pulse oximetry |
| Pilot randomized control trial of EKG for neonatal resuscitation | Katheria | Level 1 | Time to clinical intervention with blinded and unblinded available bedside EKG monitoring | Intervention s started earlier in unblended EKG group but no significant difference due to small n | ECG provides more accurate HR and pulse oximetry, allowing earlier intervention |
| ECG is more reliable than pulse oximetry to detect bradycardia during stabilization at birth of very preterm infants | Iglesias | Level 1 | Number of episodes of bradycardia detected from pulse oximetry and ECG | Pulse oximetry did not detect the start of bradycardia in 69% of cases | Pulse oximetry detects start and recovery of bradycardia less accurately than ECG |
| Providing PEEP during neonatal resuscitation : which device is best | Dawson | Level 3 | measured PIP and PEEP, leak during simulated resuscitation | T piece and self-inflating bag had least leak; T piece most accurate PIP; T piece with most accurate PEEP | T piece most accurately provided PIP/PEEP, flow inflating bag had most variation |
| Comparison of devices for newborn ventilation in the DR | Carlo | Level 2 | Incidence of HR>100 t 2 minutes of life with t piece resuscitator and self-inflating bag | No difference in achieving HR, less DR intubation with t piece | No difference between T piece resuscitator and selfinflating bag in achieving HR>100 at 2 minutes, but T piece decreased intubation rate and maximum pressures used |
| Oxygen saturation and heart rate ranges in very preterm infants requiring respiratory support at birth | Schmolzer | Level 4 | Difference in HR and oxygen saturations between CPAP or PPV at birth | Infants <28 weeks receiving CPAP reached SpO2 and HR targets faster than infants receiving PPV | Infants <28 weeks who received CPAP achieved targeted SpO2 and HR sooner than PPV |
| COIN | Morely | Level 1 | Rate of death or BPD with intubation and ventilation vs. CPAP at 5 minutes after birth | Lower risk of death and need for oxygen at 28 days with infants receiving CPAP | CPAP group spent less time on mechanical ventilation, surfactant need was almost half, lower requirement of postnatal steroids |
| SUPPORT | Finer | Level 1 | Death or BPD with DR CPAP vs invasive ventilation | Infants receiving CPAP required less intubation, mechanical ventilation and postnatal steroids | CPAP is alternative to intubation and surfactant in DR management |
| VON DRM, 3 approaches to initial respiratory managemen t of preterm neonates | Soll | Level 2 | Difference in mortality and BPD between PS with MV, PS with rapid extubation or CPAP only | RR BPD or death 0.83 (95% CI 0.52-1.29) for CPAP compared to PS | CPAP group had less need of surfactant, intubation and mechanical ventilation |
| Cochrane review | Soll | Level 1 | Surfactant administration within 1-2 h of birth vs delayed surfactant administration | reduction for mortality, air leak syndrome, IVH, PIE and BPD | Early surfactant leads to decreased of acute pulmonary injury, decreased risk of mortality and CLD |
Literature summary
CPAP vs. Intubation/surfactant/ventilation as initial respiratory management in the delivery room – randomized trials
Three randomized clinical trials have compared delivery room CPAP to mandatory intubation and ventilation. In the COIN trial, Morley, et al. studied 610 infants born at 25-28 weeks’ gestational age. They found a non-statistically significant trend toward decreased rate of the primary outcome, death or BPD at 36 weeks corrected age, in the CPAP group (33.9% vs. 38.9%, OR 0.80, 95% CI 0.58, 1.12) (Morley, et al., NEJM, 2008). In the SUPPORT trial, the NICHD Neonatal Research Network randomized 1316 infants born at 24-27 6/7 weeks to early CPAP in the delivery room or intubation and surfactant (Finer, et al., NEJM, 2010). Again, the authors found a non-statistically significant trend toward decreased rate of the primary outcome, death or BPD at 36 weeks, in the CPAP group (47.8% vs. 51.0%, RR 0.95, 95% CI 0.85, 1.05). In this study, there were more infants in the CPAP arm alive and extubated at 7 days of life (55.3% vs. 48.8%, p=0.01) and fewer infants in the CPAP arm who received steroids for BPD (7.2% vs. 13.2%, p<0.001). Finally, a Vermont Oxford Network study randomized 648 infants born at 26- 29 6/7 weeks’ gestation to intubation/prophylactic surfactant/mandatory ventilation, intubation/prophylactic surfactant/extubation to CPAP, or CPAP alone (Dunn, et al., EPAS, 2010). They also found a non-statistically significant trend toward decreased of death or BPD at 36 weeks in the CPAP group, when compared to the group who received mandatory ventilation in the delivery room (30.5% vs. 36.5%, OR 0.83, 95% CI 0.64, 1.09). When the 2358 infants from these studies are combined, there is a highly significant reduction in the odds of death or BPD at 36 weeks corrected age associated with the use of CPAP in the delivery room, odds ratio 0.80 (95% CI 0.68, 0.94). Per the most recent guidelines from the AAP Committee on the Fetus and Newborn (2014), “the early use of CPAP with subsequent selective surfactant administration in extremely preterm infants results in lower rates of BPD/death when compared with treatment with prophylactic or early surfactant therapy.”
Heart Rate Monitoring in the Delivery Room
Improvement in a ELBW infant’s heart rate is the most reliable indicator of improving ventilation. Bradycardia has been shown to be the most frequent indication for delivery room intubations, with 34% of documented reasons for intubations per Kakkilaya et al (Pediatrics 2019). Two studies in 2015 demonstrated that HR measurement by pulse oximeter relayed lower HR as compared to ECG (Narayan et all, van Vonderen et al).
Intubation and Surfactant Administration
Cochrane’s meta-analysis in 2012 compared outcomes of premature infants who received surfactant within 2 hours of life and those who received delayed surfactant (after 2 hours of life). Evidence showed that early selective surfactant administration given to infants with RDS requiring assisted ventilation leads to a decreased risk of acute/subacute pulmonary injury (air-leak syndrome, pulmonary interstitial emphysema, pulmonary hemorrhage), mortality and chronic lung disease compared to delaying treatment of such infants until they develop worsening RDS.
Previous Consensus Statement or Data from Division of Neonatology
CHOP/HUP 2010, Management of the Extremely Low Birthweight Infant in the Delivery Room
Consensus statement and clinical recommendations
- These recommendations refer specifically to the immediate resuscitation period after delivery, in the first 10 minutes of life
- These recommendations apply to infants <32 weeks
- ECG monitoring as soon after birth as possible is recommended
- T piece resuscitator for initial resuscitation is recommended over other ventilation devices
- Consideration should be given for use of Video Laryngoscopy in the DR when available
Oxygen Saturation Targeting:
Follow NRP standards for oxygen saturation targeting goals 7th Ed:
| 1 minute | 60-65% |
| 2 minutes | 65-70% |
| 3 minutes | 70-75% |
| 4 minutes | 75-80% |
| 5 minutes | 80-85% |
| 6 minutes | 85-95% |
- Pulse oximeter is placed on a preductal location on the right upper extremity, usually wrist or palm, as soon as possible.
- Oxygen concentration is started at 21-30%. The oxygen concentration should be adjusted to achieve the targeted SpO2 levels, monitored by the pulse oximeter.
- Consideration for starting at FiO2 of 30% for neonates born < 28 weeks GA
- If Chest compressions are initiated, oxygen concentration is increased to 100% and weaned rapidly when the heart rate recovers and compressions are no longer needed.
- Oxygen concentrations are adjusted to maintain saturations that match recommended range for each minute after birth.
Respiratory support
First Intention Support
a. 22 to 23+6 wks GA: First intention intubation is recommended
b. 24+0 to 24+6 wks GA: Clinical judgement to be used in the DR based on neonate’s respiratory status, first intention CPAP may be considered
c. >25 wks GA: Non-invasive respiratory support is the first line therapy for all spontaneously breathing infants 25 to 32 weeks gestational age
- HR assessment is critical and ECG monitoring is recommended.
- Immediately initiate CPAP 5cm H2O and titrate (max 8cm H2O) to reduce work of breathing and O2 requirement
- If PPV is required, gentle ventilation is provided with initial PIP 20cm H2O, with increase to 25-30cm H2O as needed.
- Avoid using RAM cannula for initial resuscitation; nasal CPAP or facial CPAP is recommended
Intubation and surfactant administration
Intubation criteria:
a. First intention intubation for neonates between 22 and 23+6 weeks GA
b. Persistent apnea at 5 minutes of life
c. Bradycardia <100 despite optimal CPAP/PPV support
d. Note: FiO2 requirement in the DR/OR should NOT be a primary indicator for intubation/surfactant administration 7
- Check ET tube placement with auscultation, colorimetric CO2 detector, and/or chest x-ray
- Surfactant administration per institutional guidelines/practices Note: ETT should not be suctioned for 2 hours following surfactant administration unless signs of significant airway obstruction
References
- Aldana-Aguirre et al. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2017;102:F17-23
- Anderson JC, et al. Effect of ventilation rate on instilled surfactant distribution in the pulmonary airways of rats. J Appl Physiol 2004;97:45-56
- Anton O, Fernandez R, Rendon-Morales E et al. Heart Rate Monitoring in Newborn Babies: A Systematic Review Neonatology 2019;116:199–210 DOI: 10.1159/000499675
- Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev. 2012; 11:CD001456
- Cassidy KJ, et al. A rate lung model of instilled liquid transport in the pulmonary airways. J Appl Physiol 2001;90:1955-67
- De Bisschop B. Early Predictors for Intubation-SURfactant-Extubation failure in preterm infants with neonatal respiratory distress syndrome: A systematic Review. Neonatology. 2020, Vol.112
- Dawson JA, Gerber A, Camlin COF et al. Providing PEEP during neonatal resuscitation: Which device is best? Journal of Pediatrics and Child Health 2011: 1-6.
- Dawson JA, Schmolzer GM, Wyllie J et al. Monitoring Heart Rate in the Delivery Room. Seminars in Fetal and Neonatal Medicine 2018; 327–332
- Dunn MS, Kaempf J, de Klerk A, et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics. 2011;128(5):e1069- e1076. doi:10.1542/peds.2010-3848
- SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network, Finer NN, Carlo WA, et al. Early CPAP versus surfactant in extremely preterm infants [published correction appears in N Engl J Med. 2010 Jun 10;362(23):2235]. N Engl J Med. 2010;362(21):1970-1979. doi:10.1056/NEJMoa0911783
- Fischer HS, Buhrer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: A meta-analysis. Pediatrics. 2013; 132:e1351-60
- Iglesias B, et al. Arch Dis Child Fetal Neonatal Ed 2018;103:F233–F237. doi:10.1136/archdischild-2016-311492
- Isayama T., Chai-Adisaksopha C., McDonald SD. Noninvasive ventilation with vs without early surfactant to prevent chronic lung disease in preterm infants: A systematic review and meta-analysis. JAMA Pediatr. 2015; 169:731-9
- Katheria A, Arnell K, Brown M, Hassen K, Maldonado M, Rich W, et al. A pilot randomized controlled trial of EKG for neonatal resuscitation. PLoS ONE 2017; 12(11): e0187730.
- Martherus T, et al. Supporting breathing of preterm infants at birth: a narrative review. Arch Dis Child Fetal Neonatal Ed 2019;104:F102–F107.
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