Delivery Room Management

Purpose
To compare the effects of three distinct methods of post-delivery stabilization and subsequent respiratory care on chronic lung disease and survival in premature infants at high risk of respiratory distress syndrome:

  1. Intubation, prophylactic surfactant administration shortly after delivery, and subsequent stabilization on ventilator support (PS);
  2. Early stabilization on nasal continuous positive airway pressure with selective intubation and surfactant administration for clinical indications (nCPAP);
  3. Intubation, prophylactic surfactant administration shortly after delivery and rapid extubation to nCPAP (intubate-surfactant-extubate, ISX).

 

Study Design
Multicenter randomized trial at 27 neonatal intensive care units in the Vermont Oxford Network

Methods
Neonates (n=648) born at 26 0/7 to 29 6/7 weeks’ gestation were randomly assigned before delivery to PS, nCPAP, or ISX

Primary Outcome
Death or bronchopulmonary dysplasia (BPD) at 36 weeks’ postmenstrual age

Results
The study was halted before the desired sample size was reached because of declining enrollment. When compared with the PS group, the relative risk of BPD or death was 0.78 (95% confidence interval: 0.59-1.03) for the ISX group and 0.83 (95% confidence interval: 0.64-1.09) for the nCPAP group. There were no statistically significant differences in mortality or other complications of prematurity. In the nCPAP group, 48% were managed without intubation and ventilation, and 54% without surfactant treatment.

Conclusions
An approach that uses early nCPAP leads to a reduction in the number of infants who are intubated and given surfactant.

Publication
Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, Ferrelli K, O’Conor J, Soll RF; Vermont Oxford Network DRM Study Group. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics. 2011;128(5): e1069-e1076. PubMed: 22025591