From Liquid to Air: Breathing after Birth

      The first breaths after birth are characterized by a rapid transition from liquid- to air-filled lungs. Air is drawn into the lung during inspiration, and some remains at end expiration to establish an end-expiratory gas volume or functional residual capacity (FRC). This is usually marked by a cry, often misinterpreted as a protest from the baby. Some infants, especially those born preterm, require respiratory support during this transitional phase. To do this effectively, we need to understand the normal physiological processes occurring at this time.

      Abbreviations:

      FRC ( Functional residual capacity), NCPAP ( Nasal continuous positive airway pressure)
      To read this article in full you will need to make a payment

      References

        • Bjorklund L.J.
        • Ingimarsson J.
        • Curstedt T.
        • John J.
        • Robertson B.
        • Werner O.
        • et al.
        Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs.
        Pediatr Res. 1997; 42: 348-355
        • Wada K.
        • Jobe A.H.
        • Ikegami M.
        Tidal volume effects on surfactant treatment responses with the initiation of ventilation in preterm lambs.
        J Appl Physiol. 1997; 83: 1054-1061
        • Karlberg P.
        The adaptive changes in the immediate postnatal period, with particular reference to respiration.
        J Pediatr. 1960; 56: 585-604
        • Karlberg P.
        • Cherry R.B.
        • Escardo F.E.
        • Koch G.
        pulmonary ventilation and mechanics of breathing in the first minutes of life, including the onset of respiration.
        Acta Paediatr Scand. 1962; 51: 121-136
        • Milner A.D.
        • Sauders R.A.
        Pressure and volume changes during the first breath of human neonates.
        Arch Dis Child. 1977; 52: 918-924
        • Saunders R.A.
        • Milner A.D.
        Pulmonary pressure/volume relationships during the last phase of delivery and the first postnatal breaths in human subjects.
        J Pediatr. 1978; 93: 667-673
        • Vyas H.
        • Milner A.D.
        • Hopkins I.E.
        Intrathoracic pressure and volume changes during the spontaneous onset of respiration in babies born by cesarean section and by vaginal delivery.
        J Pediatr. 1981; 99: 787-791
        • Vyas H.
        • Milner A.D.
        • Hopkin I.E.
        • Falconer A.D.
        Role of labour in the establishment of functional residual capacity at birth.
        Arch Dis Child. 1983; 58: 512-517
        • Vyas H.
        • Field D.
        • Milner A.D.
        • Hopkin I.E.
        Determinants of the first inspiratory volume and functional residual capacity at birth.
        Pediatr Pulmonol. 1986; 2: 189-193
        • Mortola J.P.
        • Fisher J.T.
        • Smith J.B.
        • Fox G.S.
        • Weeks S.
        • Willis D.
        Onset of respiration in infants delivered by cesarean section.
        J Appl Physiol. 1982; 52: 716-724
        • Harding R.
        • Hooper S.B.
        Regulation of lung expansion and lung growth before birth.
        J Appl Physiol. 1996; 81: 209-224
        • Hooper S.B.
        • Wallace M.J.
        Role of the physicochemical environment in lung development.
        Clin Exp Pharmacol Physiol. 2006; 33: 273-279
        • Lines A.
        • Hooper S.B.
        • Harding R.
        Lung liquid production rates and volumes do not decrease before labor in healthy fetal sheep.
        J Appl Physiol. 1997; 82: 927-932
        • Harding R.
        • Hooper S.B.
        • Dickson K.A.
        A mechanism leading to reduced lung expansion and lung hypoplasia in fetal sheep during oligohydramnios.
        Am J Obstet Gynecol. 1990; 163: 1904-1913
        • Brown M.J.
        • Olver R.E.
        • Ramsden C.A.
        • Strang L.B.
        • Walters D.V.
        Effects of adrenaline and of spontaneous labour on the secretion and absorption of lung liquid in the fetal lamb.
        J Physiol. 1983; 344: 137-152
        • Barker P.M.
        • Olver R.E.
        Invited review: Clearance of lung liquid during the perinatal period.
        J Appl Physiol. 2002; 93: 1542-1548
        • Jain L.
        • Dudell G.G.
        Respiratory transition in infants delivered by cesarean section.
        Semin Perinatol. 2006; 30: 296-304
        • Jain L.
        • Eaton D.C.
        Physiology of fetal lung fluid clearance and the effect of labor.
        Semin Perinatol. 2006; 30: 34-43
        • Bland R.D.
        Loss of liquid from the lung lumen in labor: more than a simple “squeeze.”.
        Am J Physiol Lung Cell Mol Physiol. 2001; 280: L602-L605
        • Olver R.E.
        • Ramsden C.A.
        • Strang L.B.
        • Walters D.V.
        The role of amiloride-blockable sodium transport in adrenaline-induced lung liquid reabsorption in the fetal lamb.
        J Physiol. 1986; 376: 321-340
        • O'Brodovich H.
        • Hannam V.
        • Seear M.
        • Mullen J.B.
        Amiloride impairs lung water clearance in newborn guinea pigs.
        J Appl Physiol. 1990; 68: 1758-1762
        • Hummler E.
        • Barker P.
        • Gatzy J.
        • Beermann F.
        • Verdumo C.
        • Schmidt
        • et al.
        Early death due to defective neonatal lung liquid clearance in alpha-ENaC-deficient mice.
        Nat Genet. 1996; 12: 325-328
        • Warnekros K.
        Schwangerschaft und Geburt im Rontgenbilde.
        JF Bergman, Wiesbaden1917
        • Borell U.
        • Fernstrom I.
        The shape of the foetal chest during its passage through the birth canal.
        Acta Obstet Gynecol Scand. 1962; 41: 213-222
        • Martius H.
        • Bickenbach W.
        Leherbuch der Geburtshilfe.
        George Thieme Verlag, Stuttgart1956
        • Karlberg P.
        • Adams F.H.
        • Geubelle F.
        • Wallgren G.
        Alteration of the infant's thorax during vaginal delivery.
        Acta Obstet Gynecol Scand. 1962; 41: 223-229
        • Saunders R.A.
        • Milner A.D.
        Pulmonary pressure/volume relationships during the last phase of delivery and the first postnatal breaths in human subjects.
        J Pediatr. 1978; 93: 667-673
        • Hooper S.B.
        • Kitchen M.J.
        • Wallace M.J.
        • Yagi N.
        • Uesugi K.
        • Morgan M.J.
        • et al.
        Imaging lung aeration and lung liquid clearance at birth.
        FASEB J. 2007; 21 (Epub 2007 May 29): 3329-3337
        • Miserocchi G.
        • Poskurica B.H.
        • Del Fabbro M.
        Pulmonary interstitial pressure in anesthetized paralyzed newborn rabbits.
        J Appl Physiol. 1994; 77: 2260-2268
        • Boston R.W.
        • Humphreys P.W.
        • Reynolds E.O.
        • Strang L.B.
        Lymph-flow and clearance of liquid from the lungs of the foetal lamb.
        Lancet. 1965; 10: 473-474
        • Humphreys P.W.
        • Normand I.C.
        • Reynolds E.O.
        • Strang L.B.
        Pulmonary lymph flow and the uptake of liquid from the lungs of the lamb at the start of breathing.
        J Physiol. 1967; 193: 1-29
        • Milner A.D.
        • Saunders R.A.
        • Hopkin I.E.
        Is air trapping important in the maintenance of the functional residual capacity in the hours after birth?.
        Early Hum Dev. 1978; 2: 97-105
        • Chu J.S.
        • Dawson P.
        • Klaus M.
        • Sweet A.Y.
        Lung compliance and lung volume measured concurrently in normal full-term and premature infants.
        Pediatrics. 1964; 34: 525-532
        • Milner A.D.
        • Saunders R.A.
        • Hopkin I.E.
        Effects of delivery by caesarean section on lung mechanics and lung volume in the human neonate.
        Arch Dis Child. 1978; 53: 545-548
        • Olshausen R.
        Beitrag zur Lehre vom Mechanismus der Geburt.
        Ferdinand Enke, Stuttgart1901
        • Jaykka S.
        Capillary erection and lung expansion; an experimental study of the effect of liquid pressure applied to the capillary network of excised fetal lungs.
        Acta Paediatr Suppl. 1957; 46: 1-91
        • Adams F.H.
        • Karlberg P.
        • Lind J.
        possible role of capillary erection as a cause for lung expansion.
        Clin Res. 1958; 6: 111
        • Bosma J.F.
        • Lind J.
        • Gentz N.
        Motions of the pharynx associated with initial aeration of the lungs of the newborn infant.
        Acta Paediatr Suppl. 1959; 48: 117-122
        • Bosma J.E.
        • Truby H.M.
        • Lind J.
        Studies of neo-natal transition: correlated cineradiographic and visual-acoustic observations.
        Acta Paediatr Scand. 1965 (Suppl 163:93+.)
        • Dawes G.S.
        • Mott J.C.
        • Widdicombe J.G.
        • Wyatt D.G.
        Changes in the lungs of the new-born lamb.
        J Physiol. 1953; 121: 141-162
        • Fawcitt J.
        • Lind J.
        • Wegelius C.
        The first breath: a preliminary communication describing some methods of investigation of the first breath of a baby and the results obtained from them.
        Acta Paediatr Suppl. 1960; 49: 5-17
        • Engstrom L.
        • Karlberg P.
        • Rooth G.
        • Tunell R.
        The onset of respiration, a study of respiration and changes in blood gases and acid-base balance.
        Association for the aid of crippled children, New York1966
        • Fisher J.T.
        • Mortola J.P.
        • Smith J.B.
        • Fox G.S.
        • Weeks S.
        Respiration in newborns: development of the control of breathing.
        Am Rev Respir Dis. 1982; 125: 650-657
        • Kosch P.C.
        • Stark A.R.
        Dynamic maintenance of end-expiratory lung volume in full-term infants.
        J Appl Physiol. 1984; 57: 1126-1133
        • Lindroth M.
        • Johnson B.
        • Ahlstrom H.
        • Svenningsen N.W.
        Pulmonary mechanics in early infancy.
        Pediatr Res. 1981; 15: 979-984
        • Mortola J.P.
        • Milic-Emili J.
        • Noworaj A.
        • Smith B.
        • Fox G.
        • Weeks S.
        Muscle pressure and flow during expiration in infants.
        Am Rev Respir Dis. 1984; 129: 49-53
        • Radvanyi-Bouvet M.F.
        • Monset-Couchard M.
        • Morel-Kahn F.
        • Vicente G.
        • Dreyfus-Brisac C.
        Expiratory patterns during sleep in normal full-term and premature neonates.
        Biol Neonate. 1982; 41: 74-84
        • Stark A.R.
        • Cohlan B.A.
        • Waggener T.B.
        • Frantz III, I.D.
        • Kosch P.C.
        Regulation of end-expiratory lung volume during sleep in premature infants.
        J Appl Physiol. 1987; 62: 1117-1123
        • Kosch P.C.
        • Hutchinson A.A.
        • Wozniak J.A.
        • Carlo W.A.
        • Stark A.R.
        Posterior cricoarytenoid and diaphragm activities during tidal breathing in neonates.
        J Appl Physiol. 1988; 64: 1968-1978
        • Kosch P.C.
        • Davenport P.W.
        • Wozniak J.A.
        • Stark A.R.
        Reflex control of expiratory duration in newborn infants.
        J Appl Physiol. 1985; 58: 575-581
        • England S.J.
        • Kent G.
        • Stogryn H.A.
        Laryngeal muscle and diaphragmatic activities in conscious dog pups.
        Respir Physiol. 1985; 60: 95-108
        • Harding R.
        • Johnson P.
        • McClelland M.E.
        Respiratory function of the larynx in developing sheep and the influence of sleep state.
        Respir Physiol. 1980; 40: 165-179
        • Henderson-Smart D.J.
        • Johnson P.
        • McClelland M.E.
        Asynchronous respiratory activity of the diaphragm during spontaneous breathing in the lamb.
        J Physiol. 1982; 327: 377-391
        • Frappell P.B.
        • MacFarlane P.M.
        Development of mechanics and pulmonary reflexes.
        Respir Physiol Neurobiol. 2005; 149: 143-154
        • Mead J.
        • Whittenberger J.L.
        • Radford Jr, E.P.
        Surface tension as a factor in pulmonary volume-pressure hysteresis.
        J Appl Physiol. 1957; 10: 191-196
        • Avery M.E.
        • Frank N.R.
        • Gribetz I.
        The inflationary force produced by pulmonary vascular distention in excised lungs; the possible relation of this force to that needed to inflate the lungs at birth.
        J Clin Invest. 1959; 38: 456-462
        • Gruenwald P.
        surface tension as a factor in the resistance of neonatal lungs to aeration.
        Am J Obstet Gynecol. 1947; 1947: 996
        • Agostoni E.
        • Taglietti A.
        • Agostoni A.F.
        • Setnikar I.
        Mechanical aspects of the first breath.
        J Appl Physiol. 1958; 13: 344-348
        • Gruenwald P.
        Normal and abnormal expansion of the lungs of newborn infants obtained at autopsy.
        Anat Rec. 1961; 139: 471-481
        • Avery M.E.
        • Mead J.
        Surface properties in relation to atelectasis and hyaline membrane disease.
        AMA J Dis Child. 1959; 97: 517-523
        • Hildebran J.N.
        • Goerke J.
        • Clements J.A.
        Surfactant release in excised rat lung is stimulated by air inflation.
        J Appl Physiol. 1981; 51: 905-910
        • Boon A.W.
        • Milner A.D.
        • Hopkin I.E.
        Lung expansion, tidal exchange, and formation of the functional residual capacity during resuscitation of asphyxiated neonates.
        J Pediatr. 1979; 95: 1031-1036
        • Boon A.W.
        • Milner A.D.
        • Hopkin I.E.
        Physiological responses of the newborn infant to resuscitation.
        Arch Dis Child. 1979; 54: 492-498
        • Cross K.W.
        Head's paradoxical reflex.
        Brain. 1961; 84: 529-534
        • Hull D.
        Lung expansion and ventilation during resuscitation of asphyxiated newborn infants.
        J Pediatr. 1969; 75: 47-58
        • Vyas H.
        • Milner A.D.
        • Hopkin I.E.
        • Boon A.W.
        Physiologic responses to prolonged and slow-rise inflation in the resuscitation of the asphyxiated newborn infant.
        J Pediatr. 1981; 99: 635-639
        • Gerhardt T.
        • Bancalari E.
        Chestwall compliance in full-term and premature infants.
        Acta Paediatr Scand. 1980; 69: 359-364
        • Heldt G.P.
        • McIlroy M.B.
        Dynamics of chest wall in preterm infants.
        J Appl Physiol. 1987; 62: 170-174
        • Barker P.M.
        • Gowen C.W.
        • Lawson E.E.
        • Knowles M.R.
        Decreased sodium ion absorption across nasal epithelium of very premature infants with respiratory distress syndrome.
        J Pediatr. 1997; 130: 373-377
        • Zelenina M.
        • Zelenin S.
        • Aperia A.
        Water channels (aquaporins) and their role for postnatal adaptation.
        Pediatr Res. 2005; 57: 47R-53R
        • Bolt R.J.
        • van Weissenbruch M.M.
        • Lafeber H.N.
        • Delemarre-van de Waal H.A.
        Glucocorticoids and lung development in the fetus and preterm infant.
        Pediatr Pulmonol. 2001; 32: 76-91
        • Aly H.
        • Massaro A.N.
        • Patel K.
        • El Mohandes A.A.
        Is it safer to intubate premature infants in the delivery room?.
        Pediatrics. 2005; 115: 1660-1665
        • Thomson M.A.
        Continuous positive airway pressure and surfactant; combined data from animal experiments and clinical trials.
        Biol Neonate. 2002; 81: 16-19
        • te Pas A.B.
        • Walther F.J.
        A randomized, controlled trial of delivery-room respiratory management in very preterm infants.
        Pediatrics. 2007; 120: 322-329
        • Hooper S.B.
        • Wallace M.J.
        • Kitchen M.
        • Siew M.
        • Yagi N.
        • Uesugi K.
        • et al.
        Lung aeration at birth: spontaneous breathing versus mechanical ventilation.
        Pediatric Academic Societies, 2007 (Toronto, Canada Abstract 7155.10)
        • Soll R.F.
        Prophylactic synthetic surfactant for preventing morbidity and mortality in preterm infants.
        Cochrane Database Syst Rev. 2000; (CD001079)
        • Lachmann B.
        • Berggren P.
        • Curstedt T.
        • Grossmann G.
        • Robertson B.
        Combined effects of surfactant substitution and prolongation of inspiration phase in artificially ventilated premature newborn rabbits.
        Pediatr Res. 1982; 16: 921-927
        • Song G.W.
        • Sun B.
        • Curstedt T.
        • Grossmann G.
        • Robertson B.
        Effect of amiloride and surfactant on lung liquid clearance in newborn rabbits.
        Respir Physiol. 1992; 88: 233-246