Respiratory and Cardiovascular Support

Supplemental oxygen The most fundamental form of respiratory support is simply providing air with a higher-than-normal concentration of oxygen — room air is 21% oxygen, and supplemental oxygen can be delivered at concentrations up to 100%. This is appropriate when a baby’s lungs are working but are not efficiently transferring oxygen into the blood, resulting in low oxygen saturation levels. Oxygen can be delivered by a small tube placed near the nose (nasal cannula), through a mask held near the face, or through a sealed circuit when the baby is on a ventilator. Because both too little and too much oxygen carry serious risks for premature infants — including lung damage and retinopathy — careful monitoring is essential, with the amount administered adjusted based on pulse oximetry and blood gas tests.

Continuous positive airway pressure (CPAP) CPAP delivers a constant gentle pressure into the baby’s airway through small prongs that sit just inside the nostrils or a soft mask over the nose, keeping the lungs from fully deflating at the end of each breath. Premature babies with underdeveloped or surfactant-deficient lungs tend to have airways and air sacs that collapse with each breath out, making the next breath in require tremendous effort — a condition called atelectasis. By maintaining a baseline level of pressure that holds the airway open between breaths, CPAP dramatically reduces the work of breathing and allows many babies to breathe on their own who would otherwise need a mechanical ventilator. See CPAP.

Chest physiotherapy Chest physiotherapy involves techniques such as gentle percussion (rhythmic tapping) on the chest wall and carefully positioning the baby to help loosen and mobilize secretions from the airways, making them easier to clear by coughing or suctioning. In the NICU, it is used primarily for infants with conditions that cause excessive mucus production or poor secretion clearance, such as certain types of pneumonia or after prolonged ventilation. The technique is applied gently and carefully in newborns to avoid injury, and evidence supporting its routine use has been subject to ongoing revision as clinical research has evolved.

Conventional mechanical ventilation When a baby cannot breathe adequately despite CPAP or other less invasive supports, a mechanical ventilator can take over part or all of the work of breathing. A soft plastic breathing tube (endotracheal tube) is inserted through the mouth or nose into the trachea (windpipe), and the ventilator delivers precisely controlled breaths at set rates, pressures, and oxygen concentrations. Modern neonatal ventilators can synchronize their breaths with the baby’s own breathing efforts, deliver very small tidal volumes appropriate for tiny lungs, and continuously adjust to changing conditions. Mechanical ventilation is lifesaving but carries risks including lung injury from pressure and volume, making the goal always to use the minimum support necessary and wean as quickly as possible.

High-frequency ventilation High-frequency ventilators deliver very small puffs of air at extremely rapid rates — hundreds or even thousands of cycles per minute, compared to the 30–60 breaths per minute typical of conventional ventilation. Paradoxically, this approach can oxygenate and ventilate effectively while maintaining the lungs at a stable, open volume and avoiding the large pressure swings associated with conventional ventilation, potentially reducing lung injury. High-frequency ventilation is used for premature infants with severe respiratory failure or air leak complications (such as a pneumothorax) who are not doing well on conventional ventilation, and in some centers it is used as a primary ventilation strategy from the outset.

Surfactant Surfactant is a complex mixture of fats and proteins produced by specialized cells in the lung that coats the inner surfaces of the tiny air sacs (alveoli) and dramatically reduces the surface tension that would otherwise cause them to collapse with each breath out. Premature infants — particularly those born before 28–32 weeks of gestation — produce insufficient surfactant, leading to respiratory distress syndrome (RDS), previously called hyaline membrane disease, which was the leading cause of death in premature infants before infant ventilators and then surfactant therapy became available. Artificial surfactant preparations can be instilled directly into the lungs through a breathing tube, often producing a rapid, dramatic improvement in lung function within minutes to hours of administration. See Surfactant.

Extracorporeal membrane oxygenation (ECMO) ECMO is the most extreme form of respiratory (and sometimes cardiac) support available in the NICU, used when a baby’s lungs and/or heart have failed so completely that conventional ventilation cannot sustain life. Blood is continuously pumped out of the baby’s body through large catheters, passed through an artificial membrane oxygenator that adds oxygen and removes carbon dioxide (performing the function of the lungs outside the body), and returned to the circulation — essentially a modified form of the heart-lung bypass used in open-heart surgery, but designed to support the patient for days to weeks rather than hours. ECMO requires specialized teams, carries significant risks, and is reserved for conditions considered severe enough to be otherwise fatal. See ECMO.

Delivery Room Resuscitation

Oxygen by mask In the delivery room, a small, soft-rimmed mask held gently over the newborn’s mouth and nose can deliver supplemental oxygen or room air to a baby who is breathing but has low oxygen saturation levels, or can be used as the first step in providing assisted breaths for an infant who is not breathing adequately. Current resuscitation guidelines emphasize starting with room air (or low-concentration oxygen) rather than 100% oxygen in most newborns, as excessive oxygen in the first minutes of life has been shown to be harmful, with oxygen concentration adjusted based on pulse oximetry readings.

Endotracheal tubes When a newborn is not breathing or cannot be adequately ventilated by mask, a small plastic tube (endotracheal tube, or ET tube) is inserted through the mouth or nose, past the vocal cords, and into the trachea to establish a direct, secure airway. Neonatal ET tubes come in very small sizes calibrated to the baby’s weight and gestational age. Correct placement is confirmed by observing chest rise with each breath, listening with a stethoscope, detecting carbon dioxide in exhaled gas, and — after stabilization — by chest X-ray. Intubation allows delivery of surfactant, reliable ventilation, and suctioning of the airway.

Ambu bags (self-inflating bags) An Ambu bag (a widely used brand name that has become generic) is a handheld, self-inflating rubber or silicone bag with a valve system that, when squeezed, delivers a breath to a patient through a mask or endotracheal tube. Unlike flow-inflating bags, a self-inflating bag refills automatically with room air or oxygen between squeezes without requiring a continuous gas flow source, making it ready for immediate use in any setting. In the delivery room, Ambu bags are the primary device for providing positive pressure ventilation to a newborn who is not breathing adequately, and every provider who attends deliveries must be skilled in their proper use.

Rusch bags (flow-inflating bags) A flow-inflating bag (often called an anesthesia bag or Rusch bag) is a soft, collapsible bag that inflates only when connected to a continuous source of pressurized gas (oxygen or air/oxygen blend) and is sealed against the patient’s face or airway. Unlike a self-inflating bag, it requires a continuous gas flow to work and demands more skill to use effectively, but it offers the advantage of allowing the provider to feel the compliance (stiffness) of the baby’s lungs with each breath, to provide CPAP, and to deliver precise oxygen concentrations. Many experienced neonatal resuscitators prefer flow-inflating bags for intubated infants because of the tactile feedback they provide.

Suction catheters Soft, flexible plastic catheters connected to a suction source are used to clear secretions, blood, meconium (fetal stool), or other debris from a newborn’s mouth, nose, and airway in the delivery room. Gentle suctioning of the mouth and nose may be performed if secretions are obstructing the airway, and deeper suctioning through an endotracheal tube may be necessary if the airway contains material that could obstruct breathing or cause lung damage. Current resuscitation guidelines have moved away from routine suctioning for most newborns, reserving it for specific situations where secretions are clearly interfering with breathing.

Radiant warmers (as used in the delivery room) As noted above, radiant warmers in the delivery room provide immediate warmth for the newborn during the critical first minutes of life, when the transition from the warm, wet womb to the cool, dry delivery room environment poses a significant heat loss risk. The radiant warmer provides an open, well-lit, warm working surface that allows the resuscitation team to assess and treat the baby without obstruction, while immediately countering the rapid cooling that occurs when wet skin is exposed to room air. The warmer is typically preset to maximum heat and activated before delivery so it is ready the moment the baby arrives.

Warm blankets Quickly drying and wrapping a newborn in pre-warmed blankets is among the simplest but most effective interventions for preventing hypothermia in a term or near-term newborn who does not require intensive resuscitation. Warmth is generated and stored by placing blankets in a warming cabinet before delivery. Wet blankets are immediately replaced with dry, warm ones because wet fabric actively conducts heat away from the skin. For very premature infants, plastic wrap is sometimes preferred over blankets because it prevents evaporative water loss more effectively.

Venous umbilical catheters (as used in the delivery room) If a newborn requires emergency intravenous medications — most critically, epinephrine (adrenaline) during cardiac resuscitation — the umbilical vein provides the fastest and most reliable vascular access during the first minutes after birth. A catheter can be threaded into the umbilical vein within a minute or two by a trained provider, without any special equipment beyond a sterile catheter and tray, and the medications can be delivered immediately into the central circulation. The umbilical vein emergency access approach is taught as a core skill in neonatal resuscitation training worldwide.

Last Updated on 04/06/26