Study protocol for the volume targeted mask ventilation versus pressure ventilation in preterm infants—the VOLT-trial

High-frequency ventilation versus conventional ventilation: No winner—but no loser

Invasive Mechanical Ventilation in Premature Infants: Where do we Stand Today?

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

ObjectiveMask positive pressure ventilation (PPV) in the delivery room is routinely delivered with set peak inflation pressures. To aid mask PPV, stand-alone respiratory function monitors (RFMs) have been used in...

Timing of Caffeine Therapy in Very Low Birth Weight Infants

Positive end-expiratory pressure during resuscitation at birth in very-low-birth-weight infants: A randomized controlled pilot trial

In the fall of 2005, the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations (CoSTR) as well as the American Heart Association’s Guidelines for Emergency Cardiovascular Care (ECC) were published in Circulation. The guidelines were prepared by the American Heart Association Pediatric Subcommittee and American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee based on an extensive review of the existing literature on neonatal resuscitation. The guidelines were used to develop and revise the Textbook of Neonatal Resuscitation, 5th edition, and accompanying Neonatal Resuscitation Program (NRP) education materials. Based on their findings, various changes have been made to the NRP, including new recommendations for the use of supplemental oxygen and endotracheal epinephrine. These changes have the potential for a profound impact on medical practice around the world.Newborns who do not require resuscitation generally can be identified by a rapid assessment of the following four characteristics: Of note, a fifth question, “Is the baby pink?” no longer appears as part of the rapid assessment immediately after birth.The sequential approach to a newborn in the delivery room remains the same (FigureF1). NRP providers should continue to adhere to the ABCs of resuscitation: airway before breathing before circulation. The four categories of action in sequence are: Temperature control continues to be an important focus of resuscitation research. Both hypothermia and hyperthermia may have detrimental effects. Hypothermia has a clear association with increased mortality, especially among low-birthweight infants. Hyperthermia is associated with perinatal respiratory depression, neonatal seizures, and cerebral palsy. Hyperthermia after ischemia in experimental animals is associated with worsening of cerebral injury. Efforts in the delivery room should focus on maintaining normothermic temperatures. Use of polyethylene bags in the delivery room is recommended to help maintain body temperature during resuscitation of very low-birthweight (VLBW) infants.A randomized, controlled study to assess the effectiveness of intrapartum oropharyngeal and nasopharyngeal suctioning for babies born through meconium-stained amniotic fluid found that the common, widely accepted procedure of suctioning did not reduce the incidence of meconium aspiration sydrome. Based on these findings, the new guidelines no longer recommend that all meconium-stained babies routinely receive intrapartum suctioning (ie, before delivery of shoulders). Other recommendations about neonatal suctioning after delivery remain unchanged. The vigor of the infant, rather than the consistency of the meconium-stained fluid, determines whether endotracheal suctioning is necessary.Various changes have been instituted regarding the use of supplemental oxygen in the delivery room. For term infants, 100% supplemental oxygen is recommended when an infant has cyanosis or when positive-pressure ventilation is required during resuscitation. Whether room air (or something between room air and 100% Fio2) may be as successful for resuscitation remains controversial and continues to be investigated. However, if resuscitation is started with less than 100% oxygen, supplemental oxygen up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth. If supplemental oxygen is unavailable, room air should be used to deliver positive-pressure ventilation.Both ILCOR and the NRP now recommend the use of an oxygen blender and pulse oximetry in the delivery room for preterm infants, especially those born at less than 32 weeks’ gestation. Initial resuscitation should begin with an oxygen concentration between room air and 100% oxygen (although no specific starting value is recommended), and the Fio2 should be increased only if the infant’s heart rate remains less than 100 beats/min or the infant exhibits cyanosis. The infant’s pulse oximetry reading should increase gradually toward 90% with successful resuscitation. The Fio2 should be weaned for an oxygen saturation greater than 95%. If no oxygen blender is available, 100% oxygen should be used. There is no convincing evidence that a brief period of 100% oxygen during resuscitation will be detrimental to the preterm infant. However, NRP suggests potentially transferring the mother to another facility with oxygen blenders and pulse oximeters in the delivery room prior to delivery, if possible. The potential economic impact of this major change in clinical practice may be substantial.Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised infant. Indications for positive-pressure ventilation include apnea/gasping, a heart rate of less than 100 beats/min, and persistent central cyanosis despite 100% free flow oxygen.Two types of resuscitation bags, self-inflating and flow-inflating, may be used to ventilate a baby. A third type of resuscitation device, the T-piece resuscitator, can be used to deliver positive-pressure ventilation and can deliver up to 100% oxygen. This mechanical device depends on a compressed gas source and must have a tight face-mask seal to inflate the lungs. The operator sets maximum circuit pressure and positive end expiratory pressure (PEEP). A positive-pressure breath is provided by alternately occluding and releasing the hole in the PEEP cap. Peak inspiratory pressure must be adjusted during resuscitation to achieve physiologic improvement (heart rate and color), audible breath sounds, and perceptible chest movements.It is now recommended that bag-and-mask ventilation include at least two persons, with one person performing ventilation, while the other evaluates the response. Heart rate is assessed initially, and if not improving, chest movement and breath sounds are verified. Increasing heart rate is the primary sign of effective ventilation during resuscitation. Other signs are improving color, spontaneous breathing, and improving muscle tone.The laryngeal mask airway has been shown to be effective for assisting ventilation of term and near-term newborns. Data are limited, however, for small preterm infants, and there is no direct comparison of laryngeal mask with bag-and-mask ventilation for initial resuscitation. When bag-and-mask ventilation is unsuccessful and endotracheal intubation is not possible, the laryngeal mask may be an effective alternative.The combination of an increasing heart rate and CO2 detection now is considered the primary method for confirming endotracheal tube placement and adequate ventilation. When the heart rate does not increase promptly after endotracheal intubation, use of a CO2 detector can help differentiate between tube malposition and the need for greater ventilatory support. Two types of CO2 detectors are used commonly in the delivery room to validate proper placement of the endotracheal tube. The first is a colorimetric device, the most commonly used method to detect CO2. This device connects to the endotracheal tube and changes color in the presence of CO2. The other method, capnography, relies on placement of a special electrode at the endotracheal tube connector. The capnograph displays a specific CO2 concentration and should indicate more than 2% to 3% saturation of CO2 if the tube is in the trachea. The CO2 detector should be connected as soon as the endotracheal tube has been inserted, noting the presence or absence of CO2 during exhalation. If CO2 is not detected after several positive-pressure breaths, the clinician should consider removing the tube, resuming bag-and-mask ventilation, and repeating the intubation process. It is important to note that a CO2 detector may not change color if a baby’s cardiac output is very low or absent, such as in the event of cardiac arrest.Significant changes are reflected in the dosing guidelines for endotracheal epinephrine administration. Numerous animal models and studies in adults have suggested that larger doses of endotracheal epinephrine are needed to achieve physiologic effects comparable to intravenous (IV) epinephrine doses. IV administration is preferred because endotracheal dosing is less predictable and efficacious. However, while IV access is being obtained, administration of a higher dose of endotracheal epinephrine (0.03 to 0.1 mg/kg) may be considered. The safety and efficacy of these higher doses, however, have not been studied sufficiently in neonatal resuscitation. Until such information is available, IV administration is the preferred route of delivery. A 3-mL syringe should be used for endotracheal administration and a 1-mL syringe for IV dosing. Recommended doses are: Naloxone administration is not recommended during the primary steps of resuscitation. This agent should be used only in infants who experience continued respiratory depression after positive-pressure ventilation has restored a normal heart rate and color and when there is a history of maternal narcotics within 4 hours of delivery. The preferred routes are either IV or intramuscular. Given the lack of clinical data in newborns, endotracheal administration of naloxone is not recommended.Infants who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in or transferred to an environment in which close monitoring and anticipatory care can be provided.Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range.Hypothermia may reduce the extent of brain injury following hypoxia-ischemia. There are insufficient data to recommend routine use of modest selective or systemic hypothermia after resuscitation of infants in whom asphyxia is suspected. Further clinical trials are needed to determine which infants benefit and which method of cooling is most effective as well as timing and duration of therapy. Avoidance of hyperthermia is particularly important in babies who may have had a hypoxic-ischemic event.A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes: Under any circumstances, discontinuation of resuscitation efforts may be appropriate after 10 minutes of absent heart rate following complete and adequate resuscitation efforts. Consistent, sensitive, and compassionate care for dying infants and their families requires advance preparation, coordination, training, practice, and skillful communication with cultural appropriateness.The NRP always has incorporated performance checklists and a megacode to assess behavioral and psychomotor skills as well as cognitive knowledge. Many educators have argued that this form of assessment is too subjective. In response to such arguments, the new edition of NRP incorporates a new validated and scored megacode checklist assessment. This checklist was developed using feedback from more than 800 NRP instructors and video footage from actual megacodes. A student must score greater than 85% to pass the megacode, which is a required element of course completion. The new edition also provides educational suggestions based in well-founded educational theory to improve instruction. For example, instructors are encouraged to model expert behavior prior to initiating the megacode. Bandura’s Social Behavioral Learning Theory, which deals with the acquisition of behaviors, contends that people acquire behaviors through the observation of others, and they then imitate what they have observed. As crises in the delivery room are unpredictable, so will be the students’ exposure to such emergencies. Modeling expert behavior in a training situation allows trainees to incorporate more than technical and cognitive skills into their internal database of NRP knowledge. The new edition also provides detailed suggestions aimed at enhancing the learning environment for delivery of NRP instruction.Familiarization with the changes in the new NRP guidelines should improve instructor preparedness. Timely implementation of educational plans to incorporate the guidelines into NRP training is imperative.

BackgroundImmediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85–95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3–0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence.MethodsAn international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks’ gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months’ and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity).DiscussionThe use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18–24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice.Trial registrationThe trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.

To test the hypothesis that high-frequency jet ventilation (HFJV) will reduce the incidence and/or severity of bronchopulmonary dysplasia (BPD) and acute airleak in premature infants who, despite surfactant administration, require mechanical ventilation for respiratory distress syndrome. Multicenter, randomized, controlled clinical trial of HFJV and conventional ventilation (CV). Patients were to remain on assigned therapy for 14 days or until extubation, whichever came first. Crossover from CV to HFJV was allowed if bilateral pulmonary interstitial emphysema or bronchopleural fistula developed. Patients could cross over to the other ventilatory mode if failure criteria were met. The optimal lung volume strategy was mandated for HFJV by protocol to provide alveolar recruitment and optimize lung volume and ventilation/perfusion matching, while minimizing pressure amplitude and O2 requirements. CV management was not controlled by protocol. Eight tertiary neonatal intensive care units. Preterm infants with birth weights between 700 and 1500 g and gestational age <36 weeks who required mechanical ventilation with FIO2 >0.30 at 2 to 12 hours after surfactant administration, received surfactant by 8 hours of age, were <20 hours old, and had been ventilated for <12 hours. Outcome Measures. Primary outcome variables were BPD at 28 days and 36 weeks of postconceptional age. Secondary outcome variables were survival, gas exchange, airway pressures, airleak, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), and other nonpulmonary complications. A total of 130 patients were included in the final analysis; 65 were randomized to HFJV and 65 to CV. The groups were of comparable birth weight, gestational age, severity of illness, postnatal age, and other demographics. The incidence of BPD at 36 weeks of postconceptional age was significantly lower in babies randomized to HFJV compared with CV (20.0% vs 40.4%). The need for home oxygen was also significantly lower in infants receiving HFJV compared with CV (5.5% vs 23.1%). Survival, incidence of BPD at 28 days, retinopathy of prematurity, airleak, pulmonary hemorrhage, grade I-II IVH, and other complications were similar. In retrospect, it was noted that the traditional HFJV strategy emphasizing low airway pressures (HF-LO) rather than the prescribed optimal volume strategy (HF-OPT) was used in 29/65 HFJV infants. This presented a unique opportunity to examine the effects of different HFJV strategies on gas exchange, airway pressures, and outcomes. HF-OPT was defined as increase in positive end-expiratory pressure (PEEP) by >/=1 cm H2O from pre-HFJV baseline and/or use of PEEP of >/=7 cm H2O. Severe neuroimaging abnormalities (PVL and/or grade III-IV IVH) were not different between the CV and HFJV infants. However, there was a significantly lower incidence of severe IVH/PVL in HFJV infants treated with HF-OPT compared with CV and HF-LO. Oxygenation was similar between CV and HFJV groups as a whole, but HF-OPT infants had better oxygenation compared with the other two groups. There were no differences in PaCO2 between CV and HFJV, but the PaCO2 was lower for HF-LO compared with the other two groups. The peak inspiratory pressure and DeltaP (peak inspiratory pressure-PEEP) were lower for HFJV infants compared with CV infants. HFJV reduces the incidence of BPD at 36 weeks and the need for home oxygen in premature infants with uncomplicated RDS, but does not reduce the risk of acute airleak. There is no increase in adverse outcomes compared with CV. HF-OPT improves oxygenation, decreases exposure to hypocarbia, and reduces the risk of grade III-IV IVH and/or PVL.

Historical Perspectives

This section is under preparation and will be included in the next issue. The objective of this review was to determine whether the elective (commencing soon after initiation of mechanical ventilation) use of high frequency jet ventilation (HFJV), as compared to conventional ventilation (CV) in preterm infants with respiratory distress syndrome (RDS), would decrease the incidence of chronic lung disease (CLD) without adverse effects. Randomized trials from MEDLINE were identified by means of MeSH and text words 'high frequency ventilation', 'high frequency jet ventilation', 'jet ventilation' from the years 1980 to 1997. The EMBASE database, the Oxford Database of Perinatal Trials, the Neonatal Trials Register of the Neonatal Review Group of the Cochrane Collaboration and the Cochrane library were also accessed. Proceedings of recent SPR/APS meetings were hand searched. Information was obtained from experts in the field, and cross references were checked. All randomized controlled trials of elective high frequency jet ventilation versus conventional ventilation in preterm infants born at less than 35 weeks GA or with a birth weight less than 2000 gms with respiratory distress were included in the systematic review. Trials which used HFJV to 'rescue' preterm infants due to severe respiratory distress usually beyond 24 hours, and trials that used HFJV for a mandatory time period and then switched back to CV, were not included in this review. The standard methods of the Neonatal Cochrane Review Group were used, including independent trial assessment and data extraction. Data were analysed using relative risk (RR) and risk difference (RD). From 1/RD the number needed to treat (NNT) for benefits and number needed to harm (NNH) for adverse outcomes were calculated. Overall analysis of the three trials showed that HFJV is associated with a reduction in CLD at 36 weeks postmenstrual age in survivors [RR 0.58 (0.34, 0. 98), RD -0.138 (-0.268, -0.007), NNT 7 (4, 90)]. The use of home oxygen therapy was evaluated in only one study (Keszler 1997) and a lower rate was found in the HFJV group [RR 0.24 (0.07, 0.79), RD -0. 176 (-0.306, -0.047), NNT 5 (3, 21)]. Overall there was a trend towards an increase in the risk of PVL in the HFJV group, which was not significant. Subgroup analyses shows a significant increase in risk of PVL in the trial by Wiswell 1996 [RR 5.0 (1.19, 21.04), RD 0.250 (0.069, 0.431), NNH 4.0 (2.3,14.5)] where a 'low volume strategy' was the standard protocol for HFJV. In the other trial by Keszler 1997, where the intention was to use a 'high volume strategy', there was no significant difference in the incidence of PVL, RR 0.42 (0.14, 1.30). In the overall analysis, there were no significant differences in the incidence of neonatal mortality, IVH all grades or in grades 3 or 4 IVH. In the subgroup where 'low volume strategy' was used there was a non-significant trend toward an increase in risk of IVH all grades and grades 3 or 4 IVH. The overall analysis shows a benefit in pulmonary outcomes in the group electively ventilated with HFJV. Of concern is the significant increase in acute brain injury in one trial which used lower mean airway pressures when ventilating with HFJV. There are as yet no long term pulmonary or neurodevelopmental outcomes from any of the trials. Until further studies ascertain the most appropriate strategy to routinely ventilate premature infants with HFJV safely, ventilation with HFJV cannot be recommended for preterm infants with RDS.

Background Preterm babies may need the help of a ventilator to breathe. Although the assistance of a ventilator can be life-saving, ventilators may also injure the baby’s immature lungs. Traditionally pressure-limited ventilation (PLV) techniques have been used which do not control the tidal volume (VT) entering the lungs. New volume-targeted ventilation (VTV) modes have been developed which aim to reduce lung injury by controlling the amount of air entering the lungs with each breath. This thesis studied clinical and physiological aspects of neonatal volume-targeted ventilation. Aims 1. To perform an up-to-date systematic literature review examining the effect of VTV upon clinical outcomes. 2. To examine the combined effects of VT and positive end-expiratory pressure (PEEP) during aeration of the preterm lung. 3. To report observations of Drager Babylog 8000 plus VTV in clinical practice during specific clinical situations (obstructed flow and during surfactant administration). 4. To examine the effects of specific ventilation back-up rate, circuit flow and maximum pressure (Pmax) setting during VTV with the Drager Babylog 8000 ventilator. Methods These included systematic review, meta-analysis, physiological and synchrotron-based imaging in a preterm rabbit model, and observational and interventional studies in humans. Results 1. Compared with PLV, VTV reduced the combined outcome of death or bronchopulmonary dysplasia, pneumothorax, days of ventilation, hypocarbia, and the combined outcome of periventricular leukomalacia or grade 3-4 intraventricular haemorrhage. 2. During aeration of the preterm lung, VT and PEEP had additive effects upon functional residual capacity (FRC) and lung compliance. With PEEP 10 cm H2O, using a higher VT increased the proportion of gas entering the lung bases, improving homogeneity of ventilation. However at lower PEEP, increasing VT disproportionately increased the proportion of gas entering the apical basal regions. 3. During clinical practice where VTV was provided using the Drager Babylog 8000 plus volume guarantee (VG) mode, the ventilator responded to completely obstructed gas flow by reducing the peak inflating pressure (PIP) to half-way between the maximum inflating pressure and the positive end-expiratory pressure despite not achieving the set expired tidal volume. This event was observed in most babies who received surfactant, following which PIP increased for 30-60 minutes. Target VT was less likely to be delivered if Pmax was set 10 mL/kg), compared with using Pmax 30 cm H2O for all babies, and did not impact patient stability or the number of ventilator alarms. Conclusions VTV strategies improve neonatal survival free of lung injury. The use of appropriate VT and PEEP during neonatal resuscitation may assist lung aeration; however, further studies are needed to assess lung injury. In clinical practice, the selection of appropriate ventilator parameters is important and affects how the baby and ventilator interact.

Background: Sustained lung inflation (SLI) would permit lung recruitment immediately after birth, improving lung mechanics and reducing the need for intubation and subsequent respiratory support in the neonatal intensive care unit among preterm infants. Aim of the Study: To assess the efficacy of initial sustained lung inflation compared to standard intermittent positive pressure ventilation (IPPV) in preterm infants who need resuscitation in delivery room. Methods: This was prospective randomized observational study that was conducted in the delivery room and NICU of A in shames University hospital from February 2019 to September 2019. The study included 115 preterm infants between 26 - 32 weeks of gestation who needed resuscitation at delivery room. The infants were randomly allocated into 2 groups; SLI group: included the preterm infants who received the SLI at initial inflation pressure of 25 cm H2O for 15 seconds using the Neopuff/T piece. IPPV group: preterm infants who received standard resuscitation; IPPV using the self-inflating bag. The heart rate (HR), oxygen saturation (SpO2), oxygen requirement, and intubation rate as well as need of surfactant in the delivery room were assessed. All cases were evaluated after admission to the NICU for the need of mechanical ventilation in the first 72 hours of life, death in delivery room or NICU and for bronchopulmonary dysplasia or death at 36 weeks post menstrual age (PMA). Results: The percentage of preterm infants who needed resuscitation was 25.5% from the total deliveries during the study period. 56.5% of them received SLI and 43.4% received conventional IPPV. There were no significant differences between the studied groups regarding gestational age, birth weight. Apgar score, heart rate, oxygen saturation was not significantly increased in the SLI group at fifth minutes of age. The percentage of infants who needed further resuscitation was 20% in SLI group and 12% in the IPPV group. There were no significant differences in need for surfactant, CPAP or ventilator among the studied groups. There were no significant differences in relation to complications as BPD, air leak or retinopathy and death between the two groups. Conclusion: This study showed that there was no advantage from use of SLI in delivery room using T-piece upon the conventional IPPV using self-inflating bag.

Background: A major proportion of preterm neonates require positive pressure ventilation (PPV) immediately after delivery. PPV may be administered through a face mask (FM) or nasal prongs. Current literature indicates that either of these are associated with similar outcomes. Summary: Nonetheless, FM remains the most utilized and the best choice. However, most available FM sizes are too large for extremely preterm infants, which leads to mask leak and ineffective PPV. Challenges to providing effective PPV include poor respiratory drive, complaint chest wall, weak thoracic muscle, delayed liquid clearance, and surfactant deficiency in preterm infants. Mask leak, airway obstruction, poor technique, and inappropriate size are correctable causes of ineffective PPV. Visual assessment of chest rise is often used to assess the efficacy of PPV. However, its accuracy is debatable. Though end tidal CO2 may adjudge the effectiveness of PPV, clinical studies are limited. The compliance of a preterm lung is highly dynamic. The inflating pressure set on T-piece is constant throughout the resuscitation, but the lung volume and dynamics changes with every breath. This leads to huge fluctuations of tidal volume delivery and can trigger inflammatory cascade in preterm infants leading to brain and lung injury. Respiratory function monitoring in the delivery room has potential for guiding and optimizing delivery room resuscitation. This is, however, limited by high costs, complex information that is difficult to interpret during resuscitation, and absence of clinical trials. Key Messages: This review summarizes the existing literature on PPV in preterm infants, the various aspects related to it such as the pathophysiology, interfaces, devices utilized to deliver it, appropriate technique, emerging technologies, and future directions.

The following guidelines are intended for practitioners responsible for resuscitating neonates. They apply primarily to neonates undergoing transition from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. The terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth. Approximately 10% of newborns require some assistance to begin breathing at birth. About 1% require extensive resuscitative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large number of births, a sizable number will require some degree of resuscitation. Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 4 characteristics: If the answer to all 4 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby can be dried, placed directly on the mother’s chest, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing. If the answer to any of these assessment questions is “no,” there is general agreement that the infant should receive one or more of the following 4 categories of action in sequence: