Can a Simple Change in the Face Mask Reduce Delivery Room Intubation?

5 days ago
3 min read

Choosing the Right Interface for Respiratory Support in Preterm Infants

The first few minutes after birth are among the most critical in a newborn's life. While most babies transition to breathing on their own, approximately 5–10% require respiratory support, and preterm infants are particularly vulnerable because of their immature lungs.

Positive pressure ventilation (PPV) is the cornerstone of neonatal resuscitation. However, successful ventilation depends not only on the person providing ventilation—but also on the interface used to deliver it.

Traditionally, most neonatal resuscitation programs use a face mask. Although effective, face masks can present several challenges. Mask leak, airway obstruction, poor mask positioning, and stimulation of the trigeminocardiac reflex may all reduce ventilation effectiveness and increase the likelihood that an infant requires endotracheal intubation.

Could changing the interface improve respiratory support?

That simple question formed the basis of our latest systematic review and meta-analysis.

What did we study?

We systematically reviewed all randomized controlled trials comparing nasal interfaces with traditional face masksduring delivery room respiratory support for preterm infants.

Seven randomized trials involving 1,270 preterm infants from multiple countries met our inclusion criteria.

Our primary outcome was neonatal death before hospital discharge. We also examined several clinically important secondary outcomes, including delivery room intubation, bronchopulmonary dysplasia, severe intraventricular hemorrhage, air leaks, and the need for intubation during the first 72 hours after birth.

By combining data from all available randomized trials, we aimed to provide the most comprehensive assessment of whether the choice of interface influences neonatal outcomes.

What did we find?

The primary outcome showed no significant difference in neonatal mortality between infants receiving respiratory support with a nasal interface and those supported with a face mask.

However, one finding stood out.

Infants managed with a nasal interface were 32% less likely to require delivery room intubation than infants receiving ventilation with a face mask.

Avoiding intubation during the immediate newborn transition is important because invasive ventilation may increase the risk of lung injury and expose infants to additional procedures and complications.

For other important neonatal outcomes—including bronchopulmonary dysplasia, severe intraventricular hemorrhage, air leaks, and intubation during the first 72 hours—there were no statistically significant differences between the two approaches.

Overall, nasal interfaces appeared to reduce delivery room intubation without increasing adverse neonatal outcomes.

An Important Limitation

One important aspect of this review deserves careful consideration.

Although delivery room intubation was consistently reduced across studies, the criteria used to decide when infants should be intubated differed between the individual trials.

Some studies allowed infants to remain in the delivery room longer before deciding whether intubation was necessary, whereas others transferred infants to the NICU earlier. Clinical thresholds for intubation—such as oxygen requirements or respiratory distress—also varied.

Despite these differences, the overall effect consistently favored the nasal interface.

This consistency across heterogeneous studies strengthens confidence that the observed reduction in delivery room intubation is likely to be clinically meaningful.

What Does This Mean for Clinical Practice?

Our findings suggest that the interface used during neonatal resuscitation matters.

Although nasal interfaces did not reduce neonatal mortality, they may help clinicians avoid delivery room intubation without increasing important neonatal complications.

Whether nasal interfaces should replace face masks as the preferred interface for delivery room respiratory support remains uncertain.

Larger, well-designed randomized controlled trials using standardized delivery room management protocols are now needed to determine whether these promising findings translate into improved long-term outcomes.

Take-Home Message

Small changes in neonatal resuscitation can have important consequences.

This study suggests that choosing a nasal interface instead of a face mask may reduce the need for delivery room intubation while maintaining similar neonatal outcomes.

As neonatal care continues to evolve, optimizing even the simplest aspects of respiratory support may help improve the transition from fetal to newborn life for our smallest patients.

Research4Babies

Advancing neonatal research. Sharing knowledge. Improving newborn lives.

Refernce:

Meta-analysis of nasal interfaces versus face mask during respiratory support at birth in less than 37 weeks' gestation infants. Idung EE, O'Reilly M, Morin CMD, Schmölzer GM. Pediatr Res. 2026 Jul 24. doi: 10.1038/s41390-026-05286-9.