Optimizing breathing support for extremely preterm infants in the delivery room

Each year in Canada, approximately 1,500 infants are born extremely preterm (less than 29 weeks gestation). These infants are at high risk of dying, with most requiring resuscitation right at birth. The most important part of this resuscitation is artificial breaths, given by health-care providers via face masks, called positive pressure ventilation (PPV). While lifesaving, if too much air is pumped into the lungs, it can cause lung and brain damage. However, if too little air is pumped in, the infant may be deprived of oxygen, leading to complications, even death.

Currently, health-care providers give PPV manually using pressure-limited devices. It can be hard to give the right amount of PPV. A better way would be for a ventilator to automatically adjust pressures so that the right volume of air is pumped into the lungs. This approach, called volume-targeted ventilation (VTV), is commonly used in the neonatal intensive care unit in babies with breathing tubes; however, it has not been tested in babies needing PPV right after birth.

Automated, ventilator-directed, volume-targeted mask ventilation (VTV-PPV) can be done using existing ventilators but needs careful testing. As a first step, we propose a single-centre feasibility pilot trial. This trial will a) determine if a larger trial can be done using our proposed design, b) test the safety of this approach, and c) obtain data in preparation for a larger trial. Therefore, we aim to recruit 40 infants born at 23 to 28 weeks in two years. Before birth, we will randomize each baby to either standard mask ventilation (PPV), or volume-targeted mask ventilation (VTV-PPV). We will follow babies during their hospital stay, track safety and clinical outcomes, and track how successful we are at enrolling a representative sample.

This pilot trial will pave the way for a large, international clinical trial. Ultimately, if proven effective, VTV-PPV may improve the survival and long-term outcomes of preterm infants worldwide.

Rachel Gibbs was supervised by Georg Schmolzer and her summer studentship was funded by the Stollery Children’s Hospital Foundation. She is enrolled in the Doctor of Medicine program.