**7. Treatment with oxygen**

**5. Respiratory support in delivery room**

50 Selected Topics in Neonatal Care

the use of oxygen. For measuring the arterial oxygen saturation (SpO<sup>2</sup>

positive inspiratory pressure should not exceed 20–25 cm H<sup>2</sup>

starting ventilation of term neonates with FiO<sup>2</sup>

the value of the measured SpO<sup>2</sup>

of 0.21, gradually rising the FiO<sup>2</sup>

or high levels of oxygen (FiO<sup>2</sup>

**6. Methylxanthines**

neonate in the delivery room [21, 22].

FiO<sup>2</sup>

Routine care in delivery room depends on whether we expect and take care of extreme premature neonates or near term or term neonates with breathing difficulties. In case of near term or term neonates, care starts with providing warmth, clearing airway if necessary, drying and stimulating the neonate. Care of preterm infants is different because we immediately place him/her into a heated polyethylene bag with small opening for the nose and mouth and further stabilize him/her under the heater to assure normal body temperature, prevent hypothermia and desiccation [18]. The stabilization of the neonate with RD in the delivery room comprises proper head positioning with wiping of the mouth, and rarely, in the case of more secretion, not removed by wiping, we may perform gentle suction of the neonate's mouth, then nose. We have to avoid the deep insertion of the catheter and vigorous suctioning of mouth which may cause reflex bradycardia. In the case of meconium staining and aspiration, suction of trachea under visual inspection with laryngoscopy guidance is needed first and then intubation and further washing out meconium from the trachea. In case of apnoea, gasping or bradycardia of <100 beats/minute, it is necessary to ventilate neonate's lungs with positive pressure ventilation considering the use of lowest effective inspiratory pressures and volumes to prevent damage to the lungs (barotrauma and volutrauma). Ventilation should fill neonatal lung with a gas mixture of air and oxygen. To prevent and reduce the oxidative stress, caused by excessive use of oxygen in the inspired air, it is necessary to be careful with

the pulse oximeter should be attached to the right wrist [19]. Latest guidelines recommend

of the extremely premature infants (born before 28 weeks gestation) should be started with

to 0.30. If neonate is spontaneously breathing, the constant positive pressure is applied for

a mask, nasal tubes or endotracheal tube using neonatal respirator (neonatal resuscitator; T-piece device), intended for stabilization of the neonate in the delivery room. The maximum

case of apnoea or bradycardia [6]. No differences in mortality and morbidity of premature

lung inflation efficacy and safety in the cardiopulmonary resuscitation and stabilization of the

Methylxanthines stimulate the respiratory centre to increase its responsiveness to the partial pressure of carbon dioxide in the blood and reduce respiratory depression by hypoxia. They also improve respiratory muscle strength. Therapy with caffeine has proven to reduce the

neonates have been demonstrated in comparing resuscitation starting with low (FiO<sup>2</sup>

0.30, while of very premature infants (28–31 weeks of gestation) with the FiO<sup>2</sup>

the stabilization of respiration (continuous positive airway pressure) of 6 cm of H<sup>2</sup>

0.21 and later increasing the FiO<sup>2</sup>

. Ventilation of preterm neonates should be started with FiO<sup>2</sup>

≥0.6) [20]. Currently, there is insufficient evidence of sustained

in accordance with the measured value of SpO<sup>2</sup>

) in the peripheral blood,

O, which is used only in the

according to

. Ventilation

from 0.21

O through

≤0.30)

Oxygen is necessary for aerobic metabolic processes in the body. The excess of oxygen is detrimental to neonates, particularly the premature infants with immature antioxidant, antiinflammatory mechanisms and a greater amount of free iron. Hyperoxia affects not only the lung but also other organs, with the greatest effects to central nervous system (convulsions) and eyes (retinopathy of prematurity (ROP)). In comparison with a 'higher' level of SpO<sup>2</sup> (91–95%), the 'lower' level (85–89%) has been shown to diminish the risk of ROP and BPD, but unfortunately at the same time increase mortality, the incidence of necrotizing enterocolitis and poor neuro-developmental outcome [29]. Based on research, current recommendations propose the SpO<sup>2</sup> of preterm infants who require oxygen therapy to be between 90 and 94%, setting alarm limits to 89 and 95% [6]. The SpO<sup>2</sup> of term neonates who require oxygen therapy should be above 92%.

Hypercapnia is associated with acidosis and compromised cardiovascular function, while hypocapnia decreases cerebral blood flow. There is some conflicting evidence on higher PaCO<sup>2</sup> levels and the impact on mortality, severe intraventricular haemorrhage (IVH), BPD, ROP and neurodevelopmental outcome [30, 31]. Therefore, the optimal target carbon dioxide levels are not established; based on available data, it should be between 46 in 60 mm Hg (6.1–8 kPa) for ventilated neonates.

Blood gas is monitored in arterial samples, so an indwelling arterial line is necessary in taking care of a neonate with moderate or severe RD. Venous and capillary samples are not appropriate for PaO<sup>2</sup> measurements. They may be of use for PaCO<sup>2</sup> monitoring, although they slightly overestimate it, and pH monitoring, although they slightly underestimate it.
