Optimization of manual ventilation quality using respiratory function monitoring in neonates: A two-phase intervention trial

Why Respiratory Function Monitoring Matters in Neonatal Care

Positive pressure ventilation (PPV) is the most effective intervention to stabilize neonates during resuscitation and transition after birth. Yet, the process of manual ventilation is often unmonitored, relying solely on subjective assessments of clinical signs like skin color, heart rate, and chest rise. This approach can be inconsistent and prone to error, even for seasoned clinicians. Misjudgments in ventilatory support can result in either under-inflation or over-inflation of the lungs, leading to significant complications such as hypoxia, bronchopulmonary dysplasia (BPD), or intraventricular hemorrhage (IVH).

Several studies, including a review by Polglase et al., have demonstrated that harmful ventilations during PPV can trigger proinflammatory pathways and hemodynamic changes, increasing the risk of long-term lung and brain injuries. Overinflation, in particular, can lead to severe outcomes like BPD, while excessive tidal volumes have been linked to a four-fold increase in IVH. Conversely, inadequate ventilation due to factors like mask leakage can lead to hypoxia, which, in turn, may cause long-term neurodevelopmental impairment.

Respiratory function monitors (RFMs) offer an objective way to measure key respiratory parameters like tidal volume (VTe), mask leakage, and peak inspiratory pressure (PIP). These monitors provide real-time feedback that can significantly improve ventilation quality, reducing the risks associated with both over- and under-ventilation.

Study Design and Key Findings

This two-phase intervention study was conducted to evaluate the effectiveness of an RFM in improving manual ventilation quality in neonates. The study involved 90 patients who required PPV and were assigned to either a control group (with a hidden RFM) or an intervention group (with a visible RFM). The primary outcome was the percentage of ventilations within the target VTe range of 4–8 ml/kg.

Key findings include:

• Improved Ventilation Quality: In the intervention group (visible RFM), 53.7% of ventilations were within the target tidal volume range, compared to 37.3% in the control group (p < 0.001). This significant improvement highlights the role of real-time feedback in enhancing manual ventilation practices.

• Reduced Over-Inflation: Excessive tidal volumes (>8 ml/kg), which can increase the risk of brain injury, were significantly reduced in the visible RFM group (10.9% vs. 29.5%, p = 0.004).

• Decreased Mask Leakage: The RFM also contributed to a significant reduction in mask leakage during ventilation (37.3% vs. 52.7%, p = 0.002), indicating better overall ventilation efficiency.

These results emphasize the importance of objective monitoring during PPV to avoid potentially harmful over- or under-ventilation and ensure more precise and safer ventilation practices.

Clinical Implications: Why RFM Makes a Difference

Neonatal resuscitation requires precision, especially in preterm infants who are highly vulnerable to lung injury. Traditional methods of assessing ventilation—such as observing chest rise, skin color, and heart rate—are inherently subjective and may lead to inconsistent results. RFMs offer a valuable alternative by providing real-time data on key ventilation parameters, which allows clinicians to make immediate adjustments.

Previous studies have shown that excessive tidal volumes and over-inflation during neonatal resuscitation are associated with poor long-term outcomes, including BPD and IVH. The current study demonstrates that using an RFM can significantly reduce these risks by offering continuous feedback on ventilation quality, helping clinicians stay within safe ventilation ranges.

This study aligns with previous research that has found RFMs to be highly effective in improving ventilation outcomes. Studies by Schmölzer et al. and others have highlighted the inability of providers to accurately estimate tidal volumes and mask leakage during resuscitation without the use of RFMs. By providing objective, real-time feedback, RFMs support healthcare providers in optimizing ventilation and preventing injury.

Looking Forward: Training and Implementation of RFMs in Neonatal Care

In addition to improving clinical outcomes, RFMs serve as a powerful teaching tool. In this study, the greatest improvements in ventilation quality were observed in less experienced providers, suggesting that RFMs can help train healthcare workers to better manage neonatal resuscitation. Training programs that include feedback from RFMs, alongside structured learning in simulated environments, could be instrumental in enhancing neonatal care.

The study also highlights the need for further research to explore optimal tidal volume ranges for different neonatal populations and patient-specific ventilation strategies. While the target range of 4–8 ml/kg is commonly used, it may not be suitable for all infants, especially those with varying degrees of prematurity or underlying conditions.

Limitations and Future Research

Despite the positive findings, there were limitations to the study. The non-randomized design may introduce biases, as the learning effect from phase one could carry over into phase two, affecting the results. Additionally, the study involved a broad patient population, including both preterm and term infants in different clinical settings, which could impact the generalizability of the findings.

Future studies should aim to investigate the use of RFMs in more controlled environments and explore the long-term benefits of RFMs on patient outcomes, including reductions in BPD and IVH. Research should also focus on refining training protocols for RFM use, ensuring that both new and experienced providers can fully benefit from this technology.

Conclusion

This two-phase intervention trial demonstrates the clear benefits of using a respiratory function monitor in neonatal care. By providing real-time feedback, RFMs significantly improve the quality of manual ventilation, reducing the risks associated with improper ventilation techniques. As neonatal resuscitation practices continue to evolve, RFMs are poised to become an essential tool for optimizing patient outcomes and ensuring safer, more effective care for the most vulnerable patients.

The integration of RFMs into neonatal practice offers a promising path forward, helping to reduce the occurrence of ventilator-induced lung injuries and improving overall clinical outcomes. Continued research and training will be key to unlocking the full potential of this technology in neonatal intensive care units worldwide.