Key message
1. In newborn babies who need help to breathe right after birth, in the delivery room, some studies have suggested that giving breathing support through the nose (nasal interface) is more effective than through a face mask (covers the nose and mouth) or laryngeal mask airway (LMA; a breathing tube, inserted through the mouth).
2. Giving babies breathing support through the nose compared with a face mask in the delivery room, may have little to no effect on the number of babies who die before discharge. Supporting babies to breathe through the nose may reduce the number of babies who have a breathing tube inserted into their windpipe (trachea) to assist breathing (intubation) in the delivery room. It is unclear whether this effect is due to the nasal interface alone, or is partially due to a new breathing system used in two of the included studies.
3. The evidence is very uncertain about the effect of giving breathing support with a nasal interface on the number of babies who need a breathing tube within 24 hours of birth, or during their time in hospital.
4. It appears that in the delivery room, giving newborn babies breathing support through their nose is likely to be as effective as a face mask.
What are the different ways of supporting babies' breathing in the delivery room?
Some newborn babies have difficulty breathing after birth and need help to start breathing regularly. In the delivery room, breathing support is usually given through a face mask that fits over the baby’s nose and mouth, or less frequently, through a tube that is placed through the mouth (intubated), above the baby’s windpipe (laryngeal mask airway). Babies who continue to have difficulty breathing may need to be intubated, and are supported with a breathing machine (ventilator). Some studies have suggested that giving breathing support to newborn babies through their nose may be more effective.
What did we want to find out?
We wanted to find out if giving breathing support to babies through their nose (using a nasal prong, a tube that fits into one or both nostrils, or a nasal mask, a mask placed over the nose) would result in less death, intubations, and complications after birth, compared with a face mask or a laryngeal mask airway; or if one type of nasal interface was better than another for the same results.
What did we do?
We searched for clinical trials that examined babies who received different types of breathing supports in the delivery room. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors, such as study methods and sizes.
What did we find?
We found five studies that involved 1406 babies whose breathing was supported with a nasal interface compared to a face mask in the delivery room. The studies were conducted in high-income countries across Europe and Australia; the largest study included 617 babies and the smallest included 36 babies.
We found that giving breathing support with a nasal interface in the delivery room may have little to no effect on the rate of death before discharge, compared to a face mask. It may reduce the number of newborn babies who are intubated in the delivery room, but the evidence is very uncertain. The evidence is very uncertain about the effect of giving breathing support with a nasal interface on the rate of intubation within 24 hours of birth; the rate of intubation during hospitalisation, once they leave the delivery room; or bleeding inside the brain. Using a nasal interface may have little to no effect on the rate of lung complications (e.g. chronic lung disease, or air leaks).
Despite this uncertainty, our results suggest that nasal interfaces and face masks are likely to be equally effective at giving breathing support in the delivery room.
We found one ongoing study comparing a nasal mask to a face mask to give breathing support to babies in the delivery room.
We did not find any studies that compared nasal interfaces to laryngeal mask airways or one type of nasal interface to another.
What are the limitations of the evidence?
Applying a nasal interface or face mask is difficult to conceal and caregivers in all studies were aware of which group babies were allocated to. This may lead to unequal care for different study groups. It is not clear if the effect on intubation rates in the delivery room is due to the nasal interface or a new breathing system that was used in two of the five studies included in our analysis. As a result, we have little confidence in the evidence and the results of this outcome should be interpreted with caution.
How up to date is this evidence?
The search is up to date to September 2022.
Nasal interfaces were found to offer comparable efficacy to face masks (low- to very low-certainty evidence), supporting resuscitation guidelines that state that nasal interfaces are a comparable alternative to face masks for providing respiratory support in the DR.
Resuscitation with a nasal interface may reduce the rate of intubation in the DR when compared with a face mask. However, the evidence is very uncertain. This uncertainty is attributed to the use of a new ventilation system in the nasal interface group in two of the five trials. As such, it is not possible to differentiate separate, specific effects related to the ventilation device or to the interface in these studies.
The Neonatal Task Force of the International Liaison Committee on Resuscitation (ILCOR) makes practice recommendations for the care of newborn infants in the delivery room (DR). ILCOR recommends that all infants who are gasping, apnoeic, or bradycardic (heart rate < 100 per minute) should be given positive pressure ventilation (PPV) with a manual ventilation device (T-piece, self-inflating bag, or flow-inflating bag) via an interface. The most commonly used interface is a face mask that encircles the infant’s nose and mouth. However, gas leak and airway obstruction are common during face mask PPV. Nasal interfaces (single and binasal prongs (long or short), or nasal masks) and laryngeal mask airways (LMAs) may also be used to deliver PPV to newborns in the DR, and may be more effective than face masks.
To determine whether newborn infants receiving PPV in the delivery room with a nasal interface compared to a face mask, laryngeal mask airway (LMA), or another type of nasal interface have reduced mortality and morbidity. To assess whether safety and efficacy of the nasal interface differs according to gestational age or ventilation device.
Searches were conducted in September 2022 in CENTRAL, MEDLINE, Embase, Epistemonikos, and two trial registries. We searched conference abstracts and checked the reference lists of included trials and related systematic reviews identified through the search.
We included randomised controlled trials (RCTs) and quasi-RCT's that compared the use of nasal interfaces to other interfaces (face masks, LMAs, or one nasal interface to another) to deliver PPV to newborn infants in the DR.
Each review author independently evaluated the search results against the selection criteria, screened retrieved records, extracted data, and appraised the risk of bias. If they were study authors, they did not participate in the selection, risk of bias assessment, or data extraction related to the study. In such instances, the study was independently assessed by other review authors. We contacted trial investigators to obtain additional information. We completed data analysis according to the standards of Cochrane Neonatal, using risk ratio (RR) and 95% confidence Intervals (CI) to measure the effect of the different interfaces. We used fixed-effect models and the GRADE approach to assess the certainty of the evidence.
We included five trials, in which 1406 infants participated. They were conducted in 13 neonatal centres across Europe and Australia. Each of these trials compared a nasal interface to a face mask for the delivery of respiratory support to newborn infants in the DR. Potential sources of bias were a lack of blinding to treatment allocation of the caregivers and investigators in all trials.
The evidence suggests that resuscitation with a nasal interface in the DR, compared with a face mask, may have little to no effect on reducing death before discharge (typical risk ratio (RR) 0.72, 95% CI 0.47 to 1.13; 3 studies, 1124 infants; low-certainty evidence).
Resuscitation with a nasal interface may reduce the rate of intubation in the DR, but the evidence is very uncertain (RR 0.68, 95% CI 0.54 to 0.85; 5 studies, 1406 infants; very low-certainty evidence). The evidence is very uncertain for the rate of intubation within 24 hours of birth (RR 0.97, 95% CI 0.85 to 1.09; 3 studies, 749 infants; very low-certainty evidence), endotracheal intubation outside the DR during hospitalisation (RR 1.15, 95% CI 0.93 to 1.42; 1 study, 144 infants; very low-certainty evidence) and cranial ultrasound abnormalities (intraventricular haemorrhage (IVH) grade ≥ 3, or periventricular leukomalacia; RR 0.94, 95% CI 0.55 to 1.61; 3 studies, 749 infants; very low-certainty evidence). Resuscitation with a nasal interface in the DR, compared with a face mask, may have little to no effect on the incidence of air leaks (RR 1.09, 95% CI 0.85 to 1.09; 2 studies, 507 infants; low-certainty evidence), or the need for supplemental oxygen at 36 weeks' corrected gestational age (RR 1.06, 95% CI 0.8 to 1.40; 2 studies, 507 infants; low-certainty evidence).
We identified one ongoing study, which compares a nasal mask to a face mask to deliver PPV to infants in the DR. We did not identify any completed trials that compared nasal interfaces to LMAs or one nasal interface to another.