NeoSHARK: Anatomical Versus Round Facemasks for Breathing Support in Preterm and Term Newborn Infants

Delivering effective facemask ventilation is an essential component of neonatal resuscitation. However, facemask leak of up to 60% in preterm neonates and airway obstruction are common and can be associated with ineffective ventilation of the baby and clinical instability (O'Currain 2019). Multiple characteristics may influence the effectiveness of facemask ventilation, such as operator technique, infant gestation, airway anatomy and tone, as well as facemask size and shape.

The Neonatal Resuscitation Programme (NRP) allows for either type of facemask as per local practice, without recommending a particular shape of that facemask. A recent national airway survey by our group demonstrated that 8/19 centres in Ireland use both anatomical and round facemasks in clinical practice, with 11 different sizes and shapes of facemasks in clinical use in neonatal units in Ireland. While studies to date have not found a difference between anatomical and round masks in neonatal manikins, these studies only included facemask ventilation delivered with a one-handed hold, rather than a two-handed hold. Emerging evidence, including benchtop and clinical data, suggests that a two-handed hold is superior to a one-handed hold in round facemasks. The combination of an anatomical mask and a two-handed hold has not yet been studied in a clinical setting.

This study will compare the measured leak in mask ventilation with a two-handed hold, delivered by a healthcare professional in the neonatal team, using an anatomical versus a round facemask with standardised mask size. The facemasks will be assessed by a randomised controlled trial, with the anatomical mask as the intervention and the round mask as the control. The population that will be studied is neonates in the neonatal intensive care unit (NICU), at any gestation, who the clinical team have decided to intubate. A member of the research team, who will provide an out-of-hours on call service, will attend the event. The relevant outcomes will be measured by the Monivent Neo100, which will be set up by the research team. Standardised mask size, as per local protocol, will be used, with the sensor module placed between the mask and the T-piece with an adaptor. The outcomes will assess the effectiveness of both the intervention and control, including ventilation parameters recorded by the Monivent Neo100 and the clinical stability of the patient. The primary outcome of this study is the percentage mask leak. A research team member will record data for primary and secondary outcomes. The event will be filmed for post-hoc video analysis. The outcome assessor will be blinded to the group allocation.This research project will take place over 10 months, with an interim analysis to ensure recruitment is projected to achieve sample size.

• Lowest oxygen saturation [Time frame: Over a maximum of 20 minutes]
• Highest supplemental FiO2 used during facemask ventilation [Time frame: Over a maximum of 20 minutes]
• Positive inspiratory pressure during facemask ventilation [Time frame: Over a maximum of 20 minutes]
• Percentage of obstructed breaths during facemask ventilation [Time frame: Over a maximum of 20 minutes]
• Tidal volume during facemask ventilation [Time frame: Over a maximum of 20 minutes]
• Number of times facemask position is adjusted during facemask ventilation [Time frame: Over a maximum of 20 minutes]
• Duration of facemask ventilation [Time frame: Over a maximum of 20 minutes]
• Crossover to other handhold [Time frame: Over a maximum of 20 minutes]
• User opinion of mask hold [Time frame: Over a maximum of 20 minutes]
• Lowest heart rate [Time frame: Over a maximum of 20 minutes]