Exhaled CO2 monitoring to guide non-invasive ventilation at birth: a systematic review

This is our latest review from the Neonatal Task Force within International Liaison Committee on Resuscitation

Objective: Measuring exhaled carbon dioxide (ECO2) during non-invasive ventilation at birth may provide information about lung aeration. However, the International Liaison Committee on Resuscitation (ILCOR) only recommends ECO2 detection for confirming endotracheal tube placement. ILCOR has therefore prioritised a research question that needs to be urgently evaluated: 'In newborn infants receiving intermittent positive pressure ventilation by any non-invasive interface at birth, does the use of an ECO2 monitor in addition to clinical assessment, pulse oximetry and/or ECG, compared with clinical assessment, pulse oximetry and/or ECG only, decrease endotracheal intubation in the delivery room, improve response to resuscitation, improve survival or reduce morbidity?'.

Design: Systematic review of randomised and non-randomised studies identified by Ovid MEDLINE, Embase and Cochrane CENTRAL search until 1 August 2022.

Setting: Delivery room.

Patients: Newborn infants receiving non-invasive ventilation at birth.

Intervention: ECO2 measurement plus routine assessment compared with routine assessment alone.

Main outcome measures: Endotracheal intubation in the delivery room, response to resuscitation, survival and morbidity.

Results: Among 2370 articles, 23 were included; however, none had a relevant control group. Although studies indicated that the absence of ECO2 may signify airway obstruction and ECO2detection may precede a heart rate increase in adequately ventilated infants, they did not directly address the research question.

Conclusions: Evidence to support the use of an ECO2 monitor to guide non-invasive positive pressure ventilation at birth is lacking. More research on the effectiveness of ECO2 measurement in addition to routine assessment during non-invasive ventilation of newborn infants at birth is needed.

Prospero registration number: CRD42022344849.