Volumetric capnography pre- and post-surfactant during initial resuscitation of premature infants

BACKGROUND: Volumetric capnography allows for continuous monitoring of expired tidal volume and carbon dioxide. The slope of the alveolar plateau of the capnogram (S(III)) could provide information regarding ventilation homogeneity. We aimed to assess the feasibility of measuring S(III) during newborn resuscitation and determine if S(III) decreased after surfactant indicating ventilation inhomogeneity improvement. METHODS: Respiratory function traces of preterm infants resuscitated at birth were analysed. Ten capnograms were constructed for each infant: five pre- and post-surfactant. If a plateau was present S(III) was calculated by regression analysis. RESULTS: Thirty-six infants were included, median gestational age of 28.7 weeks and birth weight of 1055 g. Average time between pre- and post-surfactant was 3.2 min. Three hundred and sixty capnograms (180 pre and post) were evaluated. There was adequate slope in 134 (74.4%) capnograms pre and in 100 (55.6%) capnograms post-surfactant (p = 0.004). Normalised for tidal volume S(III) pre-surfactant was 18.89 mmHg and post-surfactant was 24.86 mmHg (p = 0.006). An increase in S(III) produced an up-slanting appearance to the plateau indicating regional obstruction. CONCLUSION: It was feasible to evaluate the alveolar plateau pre-surfactant in preterm infants. Ventilation inhomogeneity increased post-surfactant likely due to airway obstruction caused by liquid surfactant present in the airways. IMPACT: Volumetric capnography can be used to assess homogeneity of ventilation by S(III) analysis. Ventilation inhomogeneity increased immediately post-surfactant administration during the resuscitation of preterm infants, producing a characteristic up-slanting appearance to the alveolar plateau. The best determinant of alveolar plateau presence in preterm infants was the expired tidal volume.