Oxygenation with T-Piece versus Self-Inflating Bag for ventilation of extremely preterm infants at birth

Positive end expiratory pressure (PEEP) is a key factor for the establishment and maintenance of functional residual capacity (FRC). Previous evidence has suggested a strong association between a low FRC and the subsequent development of respiratory distress syndrome (RDS) requiring ventilation. Several manual ventilation devices, including self-inflating bags (SIB), flow-inflating bags, and T-pieces are currently recommended for positive pressure ventilation (PPV) in the delivery room. Among these, the most widely used are SIBs and T-pieces. Consistent PEEP is provided during PPV with a T-piece. The addition of a PEEP-valve to a SIB allows the delivery of some PEEP, but not continuous positive airway pressure (CPAP). However, although PEEP is always used during mechanical ventilation, the use of PEEP during PPV in the delivery room is not yet recommended as a routine practice. On the other hand, studies investigating the use of PEEP during neonatal resuscitation recommend it.
On these bases, an Australian group has conducted a study with the hypothesis that the use of a T-piece rather than a SIB would result in higher oxygen saturation (SpO₂) levels at 5 minutes after birth in infants <29 weeks gestation. Five minutes after birth were chosen as the time to assess the primary outcome because the clinicians involved in the study wanted to be able to give CPAP to any infant without adequate oxygenation by this time. This study was a randomized, controlled trial of T-piece or SIB ventilation in which SpO2 was recorded immediately after birth from the right hand/wrist with a pulse oximeter set at 2-second averaging and maximum sensitivity. All resuscitations started with air.
In total, 41 infants received PPV with a T-piece and 39 infants received PPV with an SIB without a PEEP valve. At 5 minutes after birth, there was no significant difference between the median SpO2 in the T-piece and SIB groups (61% [interquantile range: 13% to 72%] versus 55% [42% to 67%]; P=0.27). More infants in the T-piece group received oxygen during resuscitation in the delivery room (41 [100%] versus 35 [90%], P=0.04). There was no difference in the groups in the use of continuous positive airway pressure, endotracheal intubation, or administration of surfactant in the delivery room. No difference was observed in the need for supplemental oxygen at 28 days or 36 weeks corrected gestational age and in mortality.
In conclusion, this randomized study suggests that there is no difference in SpO₂ at 5 minutes after birth between infants who received PPV with a T-piece and infants who received PPV with an SIB. However, the strength of this evidence may be somehow limited by the low number of patients enrolled. In future, larger studies comparing resuscitation devices are required to examine clinically important outcome measures.

Top