• 80% of extremely premature newborns breathe spontaneously after birth (O`Donnell, 2010)
• 86% of premature newborns (under 32th ) breathe during PPV in the delivery room (Shilleman, 2013)

• Clinical monitoring of spontaneous respiratory activity (chest movements) in the delivery room is complex and imprecise (Poulton 2011; Shilleman, 2013)
• Anatomical and functional prematurity – extremely premature newborns are able to take their first breath but cannot spontaneously clear and aerate the lungs
• Our efforts tend to be counterproductive – irritation of reflex zones leads to iatrogenic inhibition of spontaneous breathing activity
• Secondary hypoxia

Spontaneous breathing activity is supported by gradual aeration of lungs

• Very little data

  

• Meta-analysis of 6 studies:
  • Wide variability among sites and patient groups 
  • In premature newborns, TS is performed less often
  • TS is rarely performed within the first minute of life
  • TS during the first 4 minutes of life improves oxygenation, especially in premature newborns
  • Repetitive stimulation is more effective
  • TS during mask PPV can improve the development of spontaneous respiratory activity and does not increase the risk of leaks and obstructions

Pressurized ventilation support: stratification according to the maturity of the newborn

1. A periviable newborn initially requires a higher pressure and longer inspiratory duration to achieve optimal lung inflation
2. Gentle pressure support synchronized with spontaneous breathing activity (NAVA; Neurally Adjusted Ventilatory Assist, Graseby capsule) 
3. Use of HFNC in the delivery room for gestationally older premature newborns

• Initial stabilization of premature newborns with 100% 02 resulted in higher respiratory effort, better oxygenation, and shorter duration of PPV mask, without increased risk of oxidative stress.
• Diaphragm activity measured by electromyogram was significantly higher in premature newborns stabilized with 100% oxygen.

Caffeine in the delivery room 

• Caffeine increases diaphragm activity and respiratory volume

Kraaijenga G. J. H. J. V. et al, The Effect of Caffeine on Diaphragmatic Activity and Tidal Volume in Preterm Infants. The Journal of Pediatrics (2015)

• A small randomized clinical trial showed a trend towards reduced number of intubations by 12 hours of life, significant increase in mean blood pressure and higher SVC 

Katheria, A. C. et al. A pilot randomized controlled trial of early versus routine caffeine in extremely premature infants. Am. J. Perinatol. 32, 879–885 (2015)

• Administration of a caffeine bolus (10 mg/kg) immediately after birth was associated with improved respiratory function in premature newborns at < 30 weeks.

Dekker, J. et al. Caffeine to improve breathing effort of preterm infants at birth: a randomized controlled trial. Pediatr. Res. 82, 290–296 (2017).



Summary: 
support of spontaneous breathing activity and aeration of the lungs

• Delayed ligation of the umbilical cord
• Tactile stimulation
• Gentle pressure support ideally synchronized with spontaneous breaths 
• Appropriate interface
• Oxygen therapy
• Caffeine application?