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Cardiorespiratory interactions during the transitional period in extremely preterm infants: a narrative review

Pediatric Research volume 97, pages 871–879 (2025)Cite this article

Abstract

We aimed to review the physiology and evidence behind cardiorespiratory interactions during the transitional circulation of extremely preterm infants with fragile physiology and to propose a framework for future research. Cord clamping strategies have a great impact on initial haemodynamic changes, and appropriate transition can be facilitated by establishing spontaneous ventilation before cord clamping. Mechanical ventilation modifies preterm transitional haemodynamics, with positive pressure ventilation affecting the right and left heart loading conditions. Pulmonary vascular resistances can be minimized by ventilating with optimal lung volumes at functional residual capacity, and other pulmonary vasodilator treatments such as inhaled nitric oxide can be used to improve ventilation/perfusion mismatch. Different cardiovascular drugs can be used to provide support during transition in this population, and it is important to understand both their cardiovascular and respiratory effects, in order to provide adequate support to vulnerable preterm infants and improve outcomes. Current available non-invasive bedside tools, such as near-infrared spectroscopy, targeted neonatal echocardiography, or lung ultrasound offer the opportunity to precisely monitor cardiorespiratory interactions in preterm infants. More research is needed in this field using precision medicine to strengthen the benefits and avoid the harms associated to early neonatal interventions.

Impact

  • In extremely preterm infants, haemodynamic and respiratory transitions are deeply interconnected, and their changes have a key impact in the establishment of lung aireation and postnatal circulation.

  • We describe how mechanical ventilation modifies heart loading conditions and pulmonary vascular resistances in preterm patients, and how hemodynamic interventions such as cord clamping strategies or cardiovascular drugs affect the infant respiratory status.

  • Current available non-invasive bedside tools can help monitor cardiorespiratory interactions in preterm infants. We highlight the areas of research in which precision medicine can help strengthen the benefits and avoid the harms associated to early neonatal interventions.

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Fig. 1: Cardiorespiratory interactions arising from ventilating the preterm newborn lungs before and after establishment of spontaneous ventilation.
Fig. 2: Relation between different lung volumes and pulmonary vascular resistances.
Fig. 3: Normal and abnormal cardiorespiratory transitions and pathophysiology of acute pulmonary hypertension in preterm infants.

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Data availability

The data from the literature searches performed during the current study are available from the corresponding author on reasonable request.

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Funding

This article did not receive any specific financial assistance. G.S.G. is funded by the program Rio Hortega, co-funded by the Spanish Ministry of Science and the European Union.

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Authors and Affiliations

  1. Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain

    Gonzalo Solís-García, María Carmen Bravo & Adelina Pellicer

  2. Consultant Neonatologist, Rotunda Hospital, Dublin, Ireland

    María Carmen Bravo

Authors
  1. Gonzalo Solís-García
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  2. María Carmen Bravo
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  3. Adelina Pellicer
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Contributions

Gonzalo Solís García, María Carmen Bravo and Adelina Pellicer conceptualized and designed the project. Gonzalo Solís García performed the literature search and wrote the initial draft of the manuscript. María Carmen Bravo and Adelina Pellicer critically reviewed and edited the original manuscript. All three authors have approved the final version of the article.

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Correspondence to Gonzalo Solís-García.

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Solís-García, G., Bravo, M.C. & Pellicer, A. Cardiorespiratory interactions during the transitional period in extremely preterm infants: a narrative review. Pediatr Res 97, 871–879 (2025). https://doi.org/10.1038/s41390-024-03451-6

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