What is the initial approach to resuscitation for extremely preterm neonates at delivery?

Initial Approach to Resuscitation for Extremely Preterm Neonates at Delivery

Resuscitation of extremely preterm neonates should begin with low oxygen concentration (21-30%), CPAP for spontaneously breathing infants with respiratory distress, and positive pressure ventilation for apneic infants, while maintaining normothermia through additional warming techniques.

Pre-Delivery Preparation

• Anticipate the need for resuscitation by identifying risk factors before birth 1
• Ensure at least one person skilled in neonatal resuscitation is present, with someone capable of performing complete resuscitation (including intubation and medications) readily available 1
• Prepare necessary equipment, including:
  • Radiant warmer
  • Suction equipment
  • Ventilation devices (flow-inflating bag, self-inflating bag, or T-piece resuscitator)
  • Pulse oximeter
  • Additional warming techniques for preterm infants (plastic wrap, preheated room)

Initial Steps (First 30 Seconds)

1. Thermal management (critical for extremely preterm infants)

   • Place infant under radiant warmer 1
   • For infants <35 weeks: Use plastic wrap/bag up to neck level after drying 1
   • Consider preheating delivery room to 26°C 2
   • Consider exothermic mattress 2

2. Airway positioning

   • Position head in "sniffing" position to open airway 1
   • Clear airway if necessary with bulb syringe or suction catheter 1

3. Initial assessment

   • Evaluate heart rate, respirations, and oxygenation 1
   • Apply pulse oximeter to right hand/wrist (preductal) 1
   • Consider 3-lead ECG for rapid and accurate heart rate assessment 1

Respiratory Support

1. For spontaneously breathing preterm infants with respiratory distress:

   • Initiate CPAP at 5-8 cm H₂O 1, 2
   • Benefits include decreased need for intubation and reduced mechanical ventilation duration 1, 3

2. For apneic infants or heart rate <100/min:

   • Begin positive pressure ventilation (PPV) with:
     • Initial oxygen concentration: 21-30% 1, 2
     • Initial inflation pressure: 20-25 cm H₂O 1, 2
     • PEEP: 5 cm H₂O 1, 2
     • Ventilation rate: 40-60 breaths/minute 2

3. Oxygen titration targets (preductal SpO₂):

   Time (min)	SpO₂ Target
   1	60-65%
   2	65-70%
   3	70-75%
   4	75-80%
   5	80-85%
   10	85-95%
   1, 2

4. Ventilation effectiveness assessment:

   • Primary indicator: Increase in heart rate 1, 2
   • Secondary indicators: Chest movement, breath sounds, improving SpO₂ 1
   • Consider respiratory mechanics monitors to prevent excessive pressures 1

Escalation of Support

1. If bradycardia persists despite effective ventilation:

   • If heart rate <60/min after 30 seconds of effective ventilation:
     • Begin chest compressions at lower third of sternum 1
     • Use two-thumb technique encircling the chest 1
     • Compression depth: one-third AP diameter of chest 1
     • 3:1 compression-to-ventilation ratio (90 compressions, 30 breaths per minute) 1
     • Increase oxygen to 100% until heart rate recovers 1, 2

2. Vascular access (if needed):

   • Preferred: Umbilical vein 2
   • Alternative: Intraosseous access 2

3. Medications (if indicated):

   • Epinephrine (0.01-0.03 mg/kg) if heart rate remains <60/min despite effective ventilation and chest compressions 2
   • Volume expansion (10 mL/kg) for suspected blood loss or shock 2

Advanced Airway Management

1. Indications for intubation:

   • Ineffective face-mask ventilation 1
   • Need for prolonged ventilation 1
   • Special resuscitation circumstances (diaphragmatic hernia, extremely low birth weight) 1

2. Alternative to intubation:

   • Laryngeal mask airway can be considered for infants ≥34 weeks gestation if face-mask ventilation is unsuccessful 1
   • Limited data for use in infants <34 weeks or <2000g 1

Common Pitfalls and Caveats

1. Oxygen management:

   • Avoid initiating resuscitation with high oxygen (≥65%) as it provides no benefit and may increase mortality 1, 4
   • Avoid hyperoxemia in preterm infants due to risk of retinopathy of prematurity 2
   • Avoid hypoxemia which can worsen pulmonary hypertension 2

2. Ventilation issues:

   • Avoid excessive inflation pressures that may cause lung injury 1
   • Recognize and correct mask leak and airway obstruction promptly 3
   • Avoid routine application of sustained inflation >5 seconds due to insufficient evidence for safety and efficacy 1

3. Temperature management:

   • Prevent hypothermia which increases mortality and morbidity in preterm infants 1, 5
   • Monitor for hyperthermia when using multiple warming techniques 1

4. Meconium management:

   • Routine tracheal suctioning for non-vigorous infants born through meconium-stained fluid is no longer recommended 1

Post-Resuscitation Care

• Continue respiratory support as needed
• Monitor oxygen saturation and adjust FiO₂ to maintain target range (90-95% for preterm infants) 2
• Monitor for complications of prematurity (respiratory distress syndrome, intraventricular hemorrhage)
• Consider surfactant administration for respiratory distress syndrome 5
• Maintain normothermia (36.5-37.5°C) 1, 2

The presence of skilled personnel trained specifically in neonatal resuscitation significantly improves outcomes for extremely preterm infants born outside tertiary centers 5, highlighting the importance of proper training and preparation for these high-risk deliveries.