Exhaled CO2 monitoring to guide non-invasive ventilation at birth: a systematic review

Abstract

Objective: Measuring exhaled carbon dioxide (ECO₂) during non-invasive ventilation at birth may provide information about lung aeration. However, the International Liaison Committee on Resuscitation (ILCOR) only recommends ECO₂ detection for confirming endotracheal tube placement. ILCOR has therefore prioritised a research question that needs to be urgently evaluated: 'In newborn infants receiving intermittent positive pressure ventilation by any non-invasive interface at birth, does the use of an ECO₂ monitor in addition to clinical assessment, pulse oximetry and/or ECG, compared with clinical assessment, pulse oximetry and/or ECG only, decrease endotracheal intubation in the delivery room, improve response to resuscitation, improve survival or reduce morbidity?'.

Design: Systematic review of randomised and non-randomised studies identified by Ovid MEDLINE, Embase and Cochrane CENTRAL search until 1 August 2022.

Setting: Delivery room.

Patients: Newborn infants receiving non-invasive ventilation at birth.

Intervention: ECO₂ measurement plus routine assessment compared with routine assessment alone.

Main outcome measures: Endotracheal intubation in the delivery room, response to resuscitation, survival and morbidity.

Results: Among 2370 articles, 23 were included; however, none had a relevant control group. Although studies indicated that the absence of ECO₂ may signify airway obstruction and ECO₂ detection may precede a heart rate increase in adequately ventilated infants, they did not directly address the research question.

Conclusions: Evidence to support the use of an ECO₂ monitor to guide non-invasive positive pressure ventilation at birth is lacking. More research on the effectiveness of ECO₂ measurement in addition to routine assessment during non-invasive ventilation of newborn infants at birth is needed.

Prospero registration number: CRD42022344849.

Keywords: neonatology; resuscitation.