RT Journal Article
SR Electronic
T1 Delivery Room Management of Extremely Low Birth Weight Infants: Spontaneous Breathing or Intubation?
JF Pediatrics
JO Pediatrics
FD American Academy of Pediatrics
SP 961
OP 967
DO 10.1542/peds.103.5.961
VO 103
IS 5
A1 Lindner, Wolfgang
A1 Voßbeck, Sabine
A1 Hummler, Helmut
A1 Pohlandt, Frank
YR 1999
UL http://pediatrics.aappublications.org/content/103/5/961.abstract
AB 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; <1000 g, ≥24 weeks).Methods. Retrospective cohort study of 123 inborn ELBWIs born in 1994 and in 1996. DR policies have changed. Until 1994, ELBWIs were intubated immediately after delivery when presenting the slightest signs of respiratory distress or asphyxia after initial resuscitation using a face mask and a handbag. During 1995, the guidelines for respiratory support were changed. In 1996, continuous (15 to 20 seconds), pressure controlled (20 to 25 cm H2O) inflation of the lungs using a nasal pharyngeal tube, followed by continuous positive airway pressure (CPAP; 4 to 6 cm H2O) was applied to all ELBWIs immediately after delivery to establish a functional residual capacity and perhaps to avoid EI/MV.In addition to the changes in respiratory support, the prevention of conductive and evaporative heat loss was improved in 1996. For analysis of morbidity and mortality, infants were matched for gestational age and birth weight.Results. The rate of EI/MV in the DR decreased from 84% in 1994 to 40% in 1996. 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 distress syndrome (RDS).Initial ventilator settings, ventilator days, mortality, and morbidity were not different between ELBWIs with EI/MV in the DR and infants with secondary 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 dysplasia, intraventricular hemorrhage >grade 2 and/or periventricular leukomalacia), mortality, and fewer hospital days (mean: 79 vs 105 days). The incidence of gastrointestinal adverse effects like feeding intolerance or necrotizing enterocolitis was not increased in 1996.Paco 2 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 spontaneously breathing infants had hypercapnia (Paco 2 ≥60 mm Hg [8.0 kPa]), compared with 7% of infants with EI/MV in 1994. Within the first few hours of life, Paco 2decreased 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 secondary 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 increasing morbidity or mortality in infants with secondary EI/MV attributable to RDS. We speculate that an individualized intubation strategy of the ELBWI is superior to immediate intubation of all ELBWIs with slight signs of respiratory distress after birth.