Using Intensive Care Technology in the Delivery Room: A New Concept for the

Resuscitation of Extremely Preterm Neonates

Máximo Vento, M. Aguar, Tina A. Leone, Neil N. Finer, Ana Gimeno, Wade Rich,
Pilar Saenz, Raquel Escrig and Maria Brugada
Pediatrics 2008;122;1113
DOI: 10.1542/peds.2008-1422

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/122/5/1113.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
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Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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COMMENTARY
Using Intensive Care Technology in the Delivery
Room: A New Concept for the Resuscitation of
Extremely Preterm Neonates
Máximo Vento, PhD, MDa, M. Aguar, MDa, Tina A. Leone, MDb, Neil N. Finer, MDb, Ana Gimeno, MDc, Wade Rich, RRTb, Pilar Saenz, MDc,
Raquel Escrig, MDa, Maria Brugada, MDa
aNeonatal Research Unit and Research Foundation and cDivision of Neonatology, Hospital Universitario Materno Infantil La Fe, Valencia, Spain; bDivision of Neonatal
Medicine, University of California San Diego School of Medicine and Medical Center, San Diego, California
The authors have indicated they have no financial relationships relevant to this article to disclose.
D ESPITE DRAMATIC IMPROVEMENTS in survival rates of
preterm infants over the last 50 years, there have
been no significant further improvements in survival or
morbidity rates over the most recent 10 years.1,2 Survival
rates among infants with a birth weight of 500 to 1500 g
in participating centers of the Eunice Kennedy Shriver
National Institute of Child Health and Human Develop-
ment Neonatal Research Network of the United States
were 84% in 1995–1996 and 85% in 1997–2002; the
survival rate without major neonatal morbidity (which
included bronchopulmonary dysplasia [BPD], intraven-
tricular hemorrhage, and necrotizing enterocolitis) was
unchanged (70%) between these 2 time periods.1 Simi-
lar findings were observed in epidemiologic data from
Norway and Germany, which were published almost
coincidentally.2,3 New paradigms for addressing care of
extremely preterm infants may be necessary to achieve
further improvements in outcome.
Before the last decade, increased survival rates of
preterm infants had been attributed to regionalization of
high-risk pregnancies, use of prenatal corticosteroids,
and an aggressive approach to perinatal therapy.4 Birth
in a high-risk perinatal center with a higher level of
neonatal care is associated with better survival rates than
birth in a center that provides a lower level of care,5 and
mortality and morbidity rates are increased for the most
immature infants who require transport after birth.6
Some of the major morbidities associated with extreme
prematurity such as BPD and intraventricular/periven-
tricular hemorrhage could potentially be affected by
management in the first minutes of life. However, the
principles of care that occur in the NICU are not always
used in the delivery room (DR). Care of the smallest
preterm infants in the DR has received very little atten-
tion in newborn-resuscitation protocols. It is only with
the most recent edition of the Neonatal Resuscitation
Program textbook7 that a chapter dedicated to preterm
infants was introduced.
The tools used during newborn resuscitation are gen-
erally rudimentary, and monitoring is traditionally based
on clinical examination alone, which can have substan-
tial subjectivity.8 Recent surveys have revealed that even
in the most developed countries, equipment used for
newborn resuscitation is frequently not any more ad-
vanced than in less developed countries.9–12 Con-
versely, adult-resuscitation protocols incorporate ad-
Downloaded from pediatrics.aappublications.org by guest on June 12, 2013
vanced monitoring from the first moments of
resuscitation.13 It seems that use of the best available
tools and principles of preterm infant care in the DR
would help achieve a stable transition from fetal life,
minimizing risks of serious morbidity.
As many as 7% of delivery services in the United
States admit infants directly into a bed in an adjacent
NICU, immediately providing an appropriate, monitored
environment.12 However, most existing facilities cannot
create such a proximal relationship between the DR and
the NICU. Equipping the existing DR resuscitation space
with supplies that are currently used routinely in the
ICU will allow a higher level of care from the first
moments of life.
Therefore, we suggest that incorporation of an inten-
sive care environment into the DR could enhance sur-
vival rates and reduce morbidity of extremely preterm
infants.
FREQUENCY OF NEWBORN RESUSCITATION AMONG
EXTREMELY PRETERM INFANTS
Although only ⬃10% of all infants require some resus-
citative interventions during the immediate transition
from fetal life,7 decreasing gestational age is associated
with increasing need for resuscitative interventions. We
reviewed DR interventions over a 5-year period from the
University of California San Diego Medical Center and
found that 92% of such infants received positive pres-
sure ventilation, 61% were intubated in the DR, 10%
received chest compressions, and 1.5% received epi-
nephrine.14 In another study, 40% of the infants at the
threshold of viability had a temperature of ⬍35°C on
admission to the ICU.15
Abbreviations: BPD, bronchopulmonary dysplasia; DR, delivery room; CPAP,
continuous positive airway pressure; PEEP, positive end-expiratory pressure; FIO2,
fraction of inspired oxygen
Opinions expressed in these commentaries are those of the author and not necessarily
those of the American Academy of Pediatrics or its Committees.
www.pediatrics.org/cgi/doi/10.1542/peds.2008-1422
doi:10.1542/peds.2008-1422
Accepted for publication Aug 4, 2008
Address correspondence to Máximo Vento, PhD, MD, Hospital Universitario Materno Infantil La Fe,
Neonatal Research Unit, Division of Neonatology, Avenida de Campanar, 21, E46009 Valencia, Spain.
E-mail: maximo.vento@uv.es or maximovento@telefonica.net
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2008 by the
American Academy of Pediatrics
PEDIATRICS Volume 122, Number 5, November 2008 1113
VENTILATION IN THE DR HAS SHORT-TERM AND-LONG-TERM
CONSEQUENCES
Ventilation is the most common resuscitative interven-
tion performed in the DR and may influence the devel-
opment of BPD.16 Barotrauma and/or volutrauma are
responsible in experimental animals for the activation of
specific genes and the subsequent release of proinflam-
matory mediators that trigger this cascade of events.17–19
In experimental animals it has been shown that signifi-
cant pathologic changes in the lung, including epithelial
damage, protein leak into the alveolar spaces, and inhi-
bition of surfactant function, may be induced by admin-
istering only a few inflations with high tidal volumes
immediately after birth and thereafter may be exacer-
bated by the use of mechanical ventilation.20–23
The occurrence of BPD varies widely according to
center, and the use of early continuous positive airway
pressure (CPAP) has been associated with low rates of
BPD.24,25 In addition, positive end-expiratory pressure
(PEEP) is considered essential during mechanical venti-
lation for any respiratory problems of the newborn.25
However, tools for providing manual ventilation do not
all have the ability to provide PEEP and CPAP. Self-
inflating bags are the most commonly used resuscitation
devices worldwide and are used in 40% of the DRs in the
United States. These devices do not provide CPAP, and
they provide inconsistent PEEP even with a PEEP
valve.26 Flow-inflating bags have the ability to provide
both CPAP and PEEP but require significant training and
experience to be used effectively.26 The T-piece resusci-
tator may be desirable because pressures, including
CPAP and PEEP, can be set and delivered at target levels
easily without a significant chance of unintended over-
shoot of pressure.27 For infants who require positive
pressure inflations, the goal is to deliver a pressure and
tidal volume that will lead to adequate lung inflation
without inducing additional lung injury. Tracy et al28
have shown that hyperventilation occurs frequently in
the intubated ventilated preterm infant during resusci-
tation when chest rise is used as a marker for determin-
ing the level of pressure delivered.
Mask ventilation can be difficult in the first minutes
of life with frequent occurrences of obstructed inflations.
Additional methods of monitoring ventilation can be
used to ensure the presence of a patent airway, such as
use of a colorimetric carbon dioxide detector or an end-
tidal carbon dioxide detector.29 Measurement of tidal
volume can be accomplished with flow sensors with
manual ventilating devices30 or with the use of mechan-
ical ventilators to provide consistent inflations. Further
evaluation using these monitoring devices may enable a
more informed approach to ventilation with the inten-
tion of limiting associated lung injury.
OXYGEN, OXIDATIVE STRESS, AND LUNG INJURY
Studies in human neonates have shown that the use of
pure oxygen during resuscitation may cause oxidative
stress,31,32 damage the myocardium and kidney,33 and/or
negatively influence survival.34–37 Two recent prospec-
tive randomized clinical trials were performed to evalu-
ate the effectiveness of variable oxygen concentration
1114 VENTO et al.
Downloaded from pediatrics.aappublications.org by guest on June 12, 2013
during newborn resuscitation of preterm infants.38,39
These trials demonstrated that successful resuscitation of
preterm infants can be achieved by using a low initial
fraction of inspired oxygen (iFIO2 ⫽ 0.30) but not air
(iFIO2 ⫽ 0.21) as the initial gas admixture. The average
oxygen concentration used to achieve target oxygen sat-
urations within the first 5 to 10 minutes of life and avoid
bradycardia was 30% to 40% in both studies. In addi-
tion, the use of a low iFIO2 allows an achievement of a
target saturation of 85% at 10 minutes after cord clamp-
ing with lower oxygen load.38 To provide adequate oxy-
genation during initial transition by using a targeted
oxygen saturation protocol in the DR, pulse oximeters,
blenders, and a source of compressed air are essential.
Because the average duration of DR care is ⬎20 minutes,
these tools are also critical for avoiding hyperoxia after
the initial transition.14
TEMPERATURE CONTROL IN THE DR
Efforts to limit heat loss of preterm infants in the DR
during resuscitation and transport have been broadly
recommended by most of the national resuscitation pro-
grams worldwide.40 Minimizing heat loss is extremely
difficult because of high evaporative heat loss exacer-
bated by a large temperature gradient from the skin to
the ambient air and physical characteristics of the pre-
mature infant.41 The use of polyethylene occlusive skin
wrapping used without drying has been shown to reduce
temperature loss in the DR.42 It is probably most sensible
to use this practice in conjunction with skin-tempera-
ture probes and servo control of radiant-warmer output
to avoid hyperthermia and a drop in the heater output
when in full-power manual mode for ⬎15 minutes. An
increase in the DR temperature will also greatly facilitate
the maintenance of adequate core temperatures in the
extremely low birth weight infant. Admission tempera-
tures that are in the hypothermic range have been as-
sociated with increased risk for mortality and late-onset
sepsis.43 Therefore, every effort should be made to keep
the preterm infant’s temperature within normal limits
during resuscitation and transport.
ADDITIONAL MONITORING
One of the most important signs of successful transition
is maintenance of a normal heart rate. The occurrence of
bradycardia is most frequently a reflection of inadequate
lung inflation, and heart rate is an important decision
point in the resuscitation protocol. Auscultation is the
most accurate clinical method of determining the heart
rate but remains difficult in some situations and occupies
1 individual during the resuscitation.44 The continuous
demonstration of heart rate allows the resuscitation
team to continuously reevaluate interventions. This can
be facilitated by the use of a monitor, such as a pulse
oximeter or electrocardiography monitor, which frees an
individual to perform other tasks. Electrocardiography
leads can be applied quickly and can provide an electro-
graphic heart rate display within 30 seconds.45 Pulse
oximeters applied immediately can provide a reliable
heart rate within 90 seconds and are also useful for
monitoring oxygenation.46 Both monitors can be used as
ongoing indicators of the adequacy of resuscitation in-
terventions.
APPLYING AVAILABLE TECHNOLOGY IN THE DR: A FUTURE
PERSPECTIVE
Accumulated evidence suggests that resuscitation of
extremely preterm infants should be individually ad-
justed and gentle. To achieve this goal, we propose the
following.
1. High-risk pregnancies should be referred, when pos-
sible, to high-risk perinatal centers at which a suffi-
cient number of trained caregivers (minimum of 3
per delivery: 1 team leader and 2 assistants) are avail-
able around the clock.
2. Every referral center should have at least 1 DR bed
equipped as if it were a NICU bed (“DRICU”) to allow
titrating FIO2 according to the infant’s needs and
should continuously monitor for clinical variables
(heart rate, pulse oxygen saturation, and tempera-
ture).
3. Ventilation equipment that can provide CPAP and
PEEP and consistent pressure delivery and/or tidal
volume monitoring should be used. This may be most
effective in the form of a neonatal ventilator or T-
piece resuscitator.
Intensive care of newborns at the highest risk begins
antenatally and should be continued with equal or
greater attention throughout transition, in the DR, and
into the NICU. Instituting such practices may help
achieve further improvements in outcome for the most
preterm infants.
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Using Intensive Care Technology in the Delivery Room: A New Concept for the
Resuscitation of Extremely Preterm Neonates
Máximo Vento, M. Aguar, Tina A. Leone, Neil N. Finer, Ana Gimeno, Wade Rich,
Pilar Saenz, Raquel Escrig and Maria Brugada
Pediatrics 2008;122;1113
DOI: 10.1542/peds.2008-1422
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/122/5/1113.full.h
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
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