Skip to main content
. 2023 Feb 10;10(2):351. doi: 10.3390/children10020351

Table 4.

Strategies for the management of preterm infants in the limit of viability (22–23 weeks GA) in the golden hour following the suggestions of neonatal centers with greater experience in the treatment of micro-preemies [13,66,70,75,115,116]. Modified from Norman et al. Semin Fetal Neonatal Med. 2022 [27].

Before birth Assemble designated staff. Brief with attending team.
Prepare delivery room. Use checklists.
Information to parents.
Thermal care Plastic bag without drying.
Radiant warmer, room temperature 21–25 °C.
Humidified, tempered (36–37 °C) gases for ventilation.
Delayed cord clamping [12] Any gestational age if resuscitation isn’t needed.
Initial ventilatory support at stabilization (while placing
ECG leads on the infant’s chest)
  • -

    22 weeks’ GA: intubation.

  • -

    23 weeks’ GA: intubation most likely needed.

  • -

    24 weeks’ GA: nCPAP, PPV by TPR or ventilator on mask/nasal prongs, DR intubation if needed
ETT size internal diameter/intubation depth
  • -

    22–23 weeks: 2.5 mm (two attempts) or 2.0 mm/5.5 cm at lip.

  • -

    24 weeks: 2.5 mm/5.5–6 cm at lip.
Initial PIP set not to exceed 20 cmH2O
(TPR flow 10 L/min) [70,75]
  • -

    22 weeks’ GA: 18 cmH2O

  • -

    23 weeks’ GA: 19 cmH2O

  • -

    24 weeks’ GA: 20 cmH2O
If use RFM set volume targeted 2.5 mL (5 mL/kg),
Ti set <1 s and RR 60/min guide by CO2et
Initial FiO2 [13] 0.3
Titration to achieve SpO2 targets of 80–85% at 5 min
Suggested first intended ventilatory settings [70,75,115] CV: PIP = 20–22 cmH2O, PEEP = 5 cmH2O, backup frequency = 40–60/min, VT = 4–6 mL/kg.
HFOV + VThf 1 mL: MAP = 10–12 cmH2O, frequency = 14–15 Hz, initial amplitude 40–50 cmH2O *, I:E 1:2 (1:1 if >15 Hz).
Saturation limits: 90–92%.
Surfactant administration within 2 h of life
After birth Debriefing with the attending team

CV = conventional ventilation, ETT = endotracheal tube, FiO2 = Fraction of inspired oxygen, GA = gestational age, HFOV = High Frequency Oscillatory Ventilation, TPR= T-piece resuscitation, MAP = mean airway pressure, nCPAP = Continuous positive airway pressure administered nasally, PEEP = positive end-expiratory pressure, PIP= peak inspiratory pressure, PPV = Positive pressure ventilation, RR = Respiratory rate, Ti = inspiratory time, VT = tidal volume, VThf = volume guarantee in high frequency oscillator ventilation. I:E = inspiration expiration ratio. * After recruitment, delimit 15–20 cmH2O above what is necessary to reach set VThf.