Objective To assess the role of nasal continuous positive airway pressure (CPAP) initiated at birth for prevention of death and bronchopulmonary dysplasia in very preterm infants. Design Systematic review. Data sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and online Pediatric Academic Society abstracts from the year of inception to June 2013. Eligibility criteria for selecting studies Randomised controlled trials evaluating the effect of nasal CPAP compared with intubation in preterm infants born at less than 32 weeks’ gestation and presenting the outcomes of either death or bronchopulmonary dysplasia, or both (defined as the need for oxygen support or mechanical ventilation at 36 weeks corrected gestation), during hospital stay. Results Four randomised controlled trials (2782 participants) met the inclusion criteria, with 1296 infants in the nasal CPAP group and 1486 in the intubation group. All the trials reported bronchopulmonary dysplasia independently at 36 weeks corrected gestation, with borderline significance in favour of the nasal CPAP group (relative risk 0.91, 95% confidence interval 0.82 to 1.01, risk difference −0.03, 95% confidence interval −0.07 to 0.01). No difference in death was observed (relative risk 0.88, 0.68 to 1.14, risk difference −0.02, −0.04 to 0.01, respectively). Pooled analysis showed a significant benefit for the combined outcome of death or bronchopulmonary dysplasia, or both, at 36 weeks corrected gestation for babies treated with nasal CPAP (relative risk 0.91, 0.84 to 0.99, risk difference −0.04, -0.07 to 0.00), number needed to treat of 25). Conclusion One additional infant could survive to 36 weeks without bronchopulmonary dysplasia for every 25 babies treated with nasal CPAP in the delivery room rather than being intubated.

Aim: The aim was to compare resuscitators' estimates of tidal volume (V_T) and face mask leak with measured values during positive pressure ventilation (PPV) of newborn infants in the delivery room. Patients and methods: The authors measured inflating pressures and V_T delivered using a respiratory function monitor, and calculated face mask leak. After 60 s of PPV, resuscitators were asked to estimate V_T and face mask leak. These estimates were compared with measurements taken during the previous 30 s. Results: The authors studied 20 infants who received a mean (SD) of 21 (6) inflations during the 30 s. The median (IQR) expired tidal volume (V_Te) delivered was 8.7 ml/kg (5.3–11.3). V_Te varied widely during each resuscitation and between resuscitators. Five resuscitators could not estimate V_Te, one overestimated and 14 underestimated their median delivered V_Te. The median (IQR) face mask leak was 29% (16–63%). Leak also varied widely during each resuscitation and between resuscitators. One resuscitator could not estimate mask leak, four overestimated leak and 15 underestimated leak. Conclusion: During face mask ventilation in the delivery room, V_T and face mask leak were large and variable. The resuscitators were unable to accurately assess their face mask leak or delivered V_T.

Introduction Preterm infants with inadequate breathing receive positive pressure ventilation (PPV) by mask with variable success. The authors examined recordings of PPV given to preterm infants in the delivery room for prevalence of mask leak and airway obstruction. Methods and patients The authors reviewed recordings of infants at 75%. Results The authors analysed recordings of 56 preterm infants. Obstruction occurred in 14 (26%) recordings and leaks in 27 (51%). Both obstruction and mask leaks were seen in eight (14%) recordings, and neither was seen in 15 (27%). Obstruction occurred at a median (IQR) of 48 (24–60) s after the start of PPV. A median (range) of 22 (3–83) consecutive obstructed inflations were delivered. Face-mask leaks occurred from the first inflation in 19/27 (70%) and in the remaining eight at a median (IQR) of 30 (24–46) s after the start of PPV. A median (range) of 10 (3–117) consecutive inflations with a leak >75% were delivered. Conclusion Airway obstruction and face-mask leak are common during the first 2 min of PPV. An RFM enables detection of important airway obstruction and mask leak.