Provision of positive pressure ventilation (PPV) to newborns asphyxiated at birth is crucial for establishing a smooth transition to extrauterine life. If unregulated, PPV induces lung injury and may lead to complications. Identifying a safe and effective modality to provide PPV, hence, becomes pivotal. A self-inflating bag (SIB) is the most common modality for providing PPV during resuscitation. The T-piece resuscitator (TPR) is an alternative device that is increasingly being used and can provide positive end expiratory pressure (PEEP) and a set positive inspiratory pressure (PIP). A recent review and meta-analysis found that use of TPR, when compared to other devices, resulted in a decrease in bronchopulmonary dysplasia and PPV duration, but did not affect mortality [1]. In TPR, tidal volume (TV) cannot be measured and respiratory rate (RR) is operator-dependent. In SIB, the PEEP valve and manometer can be attached to address its shortcomings, but the use of such modifications is limited. Since volutrauma is the main determinant of ventilator-induced lung injury, it seems physiologically reasonable to control the TV using a ventilator.

In a simulation-based pilot randomized controlled trial published in this issue of IJP, Kalane et al. evaluated the efficacy of ventilator-driven PPV using face mask in a neonatal mannequin [2]. Compared to SIB, ventilator-driven PPV resulted in significantly less mean PIP in the first 30 s (35.7 cm H2O vs. 20.3 cm H2O). Compared to TPR, it required less time (5 s vs. 3 s) to achieve visible chest rise. RR control was better in ventilator-driven PPV than TPR and SIB. Finally, the mental workload for resuscitating personnel was the least in the ventilator-driven PPV arm. Besides being a simulation-based study and using large SIB (TV 500 mL), another limitation was the lack of TV monitoring in SIB and TPR arm. Moreover, the mannequin used in the study weighed 3 kg. It would have been beneficial to use smaller models representing preterm newborns that require gentle ventilation the most. The authors postulated that a ventilator by providing PIP and RR in a safe range might lead to better outcomes. However, a large trial has failed to establish any benefit of monitoring TV, PIP, and RR with a monitor [3]. Further, it is also important to consider that during resuscitation in real scenarios, there are various factors that come into play that are not present in simulators. For instance, lung compliance can vary greatly and glottis closure may occur in babies <32 wk’ gestation, which can make ventilation difficult. Additionally, the trigemino-cardiac reflex with a mask can lead to apnea.

Nevertheless, this study provides proof-of-concept for the efficacy of ventilator-driven PPV in delivery rooms. It lays a foundation for future clinical trials, such as the upcoming multicentric trial from USA on use of ventilators for PPV in delivery room [4]. It will be prudent to identify the subgroup of newborns who may benefit the most, like extreme preterm newborns or those with lung hypoplasia. This is because of their high cost and the fact that there may not be any meaningful impact of precise ventilation on clinical outcomes in term newborns. As a single tertiary neonatal unit cannot enrol a large sample size, multicentric collaboration is necessary for future research on efficacy and feasibility of ventilator-based PPV.