Resuscitation of premature infants: what are we doing wrong and can we do better?

Neonatal resuscitation is based on experience with little evidence to support the methods advocated. Current guidelines make no distinction between the techniques for term and very premature infants. The guidelines support the use of 100%, cold, dry oxygen delivered with devices that provide variable peak inspiratory pressures and tidal volumes with no positive end-expiratory pressure (PEEP). It is possible that these techniques damage the lungs. Self-inflating resuscitation bags give no indication about leaks, produce variable inflating pressures, do not provide PEEP and cannot deliver prolonged inflations. Flow-inflating bags will not work if there is leak at the facemask and also have variable inflating pressures. Although they can provide PEEP and deliver prolonged inflations, they require considerable skill to use. The Neopuff is relatively easy to use, provides PEEP and steady inflating pressure and does not achieve the set pressures if there is a mask leak. Continuous positive airway pressure and PEEP are used in the neonatal intensive care unit to maintain lung volume. It is surprising they are not routinely recommended for resuscitation when establishing the lung volume is paramount. Volutrauma is a potential problem in neonatal resuscitation and yet none of the devices give any indication of the tidal volume delivered. There is considerable potential for improvement in techniques of neonatal resuscitation through the application of evidence already available and much scope for further research in this field.