Ventilatory Management of the Preterm Neonate in the Delivery Room
Condition: Respiratory Distress Syndrome, Newborn
MeSH terms: Respiratory Distress Syndrome; Respiratory Distress Syndrome, Newborn
Study type: Interventional
Phase: Phase 2

Summary: 
      The purpose of this study is to evaluate sustained lung inflation followed by early nCPAP as
      delivery room ventilatory management for preterm neonates at risk of respiratory distress
      syndrome in reducing their need for mechanical ventilation and ameliorating lung injury
      without inducing adverse effects compared with intermittent bag and mask ventilation.
    

Detailed description: 
      Neonatal resuscitation provides lifesaving intervention that, if properly conducted, not only
      can reduce mortality but probably can significantly decrease subsequent morbidity.

      Premature infants need appropriate respiratory support and a lung-protective strategy,
      starting from the delivery room where, on the contrary, an inadequate respiratory approach
      may influence pulmonary outcome.

      Mechanical ventilation in the form of positive pressure ventilation has remained the mainstay
      of treatment of respiratory distress syndrome (RDS) in preterm babies. In recent years, a
      number of new ventilation strategies have been introduced but the problem of bronchopulmonary
      dysplasia (BPD) has not been solved.

      Sustained lung inflation (SLI) lead to a large increase in the tidal volume and the
      functional residual capacity(FCR) as this intervention may influence the clearance of lung
      fluids and allow a more even distribution of air throughout the lungs, thus facilitating the
      formation of FRC.

      Nasal CPAP and early PEEP act through stabilization and subsequent recruitment of collapsed
      alveoli, increased FRC resulting in increased alveolar surface area for gas exchange and a
      decrease in intrapulmonary shunt .also it conserves endogenous surfactant.

      Previous studies with promising results showed that a combination of sustained lung inflation
      and early nasal CPAP may be the most effective and least injurious way to recruit the lung in
      preterm neonates at birth.

      This study will evaluate sustained lung inflation followed by early nCPAP as delivery room
      ventilatory management for preterm neonates at risk of respiratory distress syndrome in
      reducing their need for mechanical ventilation and ameliorating lung injury without inducing
      adverse effects compared with intermittent bag and mask ventilation.
    

Intervention name(s): Resuscitation of preterm neonates by sustained lung inflation through T piece device followed by CPAP; Resuscitation of preterm neonates by intermittent bag and mask ventilation using self inflating bag.
Intervention type(s): Procedure; Procedure
Intervention description(s): After oropharyngeal and nasal suctioning, if there are no signs of spontaneous breathing or breathing is insufficient and/or heart rate is below 100 bpm, the following approach will be followed:Pressure-controlled (20 cm H2O) inflation will be sustained for 15 secs, using a neonatal mask and a T-piece ventilator (NeoPuff Infant Resuscitator; Fisher & Paykel).To avoid pressure leakage, we will use a neonatal mask of appropriate size which adequately cover both the mouth and nostrils of infants. This pressure controlled inflation will be followed by CPAP at 5 Cm H2O.This procedure will be repeated a second time with a pressure of 25 cm H2O for 15 secs if breathing remained insufficient and/or the heart rate is < 100 bpm and/or the infant is cyanotic. To be followed by CPAP at 6 Cm H2O.A third puff with a pressure of 30 cm H2O for 15 secs will be used after few seconds if inadequate heart rate and respiration was not reached. This will be followed by CPAP at 7 Cm H2O.; After oropharyngeal and nasal suctioning, if there is no signs of spontaneous breathing or breathing is insufficient and/or heart rate is below 100 bpm, intermittent mask and bag ventilation will be administrated at a rate 40-60 per minute using a self-inflating bag and mask with an oxygen reservoir.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: Preterm; Neonates; Delivery room; Resuscitation; Ventilation; Neopuff; CPAP