Resuscitation in the delivery room: Lung protection from the first breath

Abstract

Resuscitation of newborninfants occurs in approximately 10% of the more than 100 millioninfants born annually worldwide. The techniques used during resuscitation, such as positive-pressure ventilation and supplemental oxygen, may revive manyinfants, but have the potential to harm their lungs. In recent years increasing attention has been applied to providing lung protection from the first breath. This paper reviews the currently available medical evidence concerning modifying aspects of delivery room management that are thought to mitigate lung injury. These include: F IO2 < 1.0; early use of continuous positive airway pressure (CPAP) and PEEP; optimizing pressure and/or volume during ventilation; sustainedinflations; need for and timing of surfactant therapy; and airway management of meconium-stained amniotic fluid. Although the evidence against 100% oxygen use is of low quality, it has been enough to alter the recommendations for oxygen use in the delivery room. It is suggested (not mandated) to use room air initially when resuscitating a termgestationinfant, and to use F IO2 < 1.0 in prematureinfants, with F IO2 adjustments depending on oximetry values. Recent studies have not indicated better outcomes in prematureinfants in whom CPAP or PEEP is applied in the delivery room. Optimal peak ventilatory pressure and tidal volume have yet to be delineated. Although an intriguing therapy, sustainedinflations have not been shown to markedly improve outcomes. Prophylactic use of surfactant in small, prematureinfants remains the accepted standard. Immediate placement on CPAP after surfactant instillation has yet to demonstrate clear-cut advantages. Finally, intrapartum oropharyngeal and nasopharyngeal suctioning of meconium-stained amniotic fluid does not improve outcomes in meconium-stainedinfants. Moreover, routine intubation and intratracheal suctioning of apparently vigorous meconiumstainedinfants do not improve outcomes. In summary, although multiple therapies are touted as protecting the lungs in the delivery room "from the first breath," to date there are scant supportive data. © 2011 Daedalus Enterprises.