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Published on: February 26, 2021
Risk Indicators for Air Leaks in Preterm Infants Exposed to Restrictive Use of Endotracheal Intubation
Helmut D Hummler1, Elisa Parys, Benjamin Mayer
1Division of Neonatology and Pediatric Critical Care, Department of Pediatrics, Children's Hospital, University of Ulm, Ulm, Germany.
Insights
This study found that while a restrictive intubation policy for preterm infants achieved high survival rates, it was linked to significant air leaks. Prenatal steroids protected against air leaks, while epinephrine and surfactant use increased risk.
Area of Science:
- Neonatal Medicine
- Pediatric Respiratory Medicine
- Critical Care
Background:
- Air leaks are a serious complication in preterm infants.
- Restrictive endotracheal intubation policies aim to minimize respiratory support invasiveness.
- Sustained inflations followed by noninvasive ventilation are an alternative delivery room strategy.
Purpose of the Study:
- To identify perinatal risk factors for air leaks in preterm infants.
- To evaluate the association of a restrictive intubation policy with air leak development.
- To analyze the impact of delivery room respiratory support on air leaks.
Main Methods:
- Retrospective analysis of 297 preterm infants (<29 weeks gestational age).
- Inclusion of perinatal and delivery room respiratory support variables.
- Multivariate logistic regression to identify independent risk indicators for air leaks.
Main Results:
- Air leaks occurred in 21.2% of infants, associated with increased mortality and severe intraventricular hemorrhage.
- Risk factors identified: less prenatal steroid use, more cardiac compressions, higher sustained inflation pressure, and delivery room intubation.
- Multivariate analysis revealed prenatal steroids as protective (OR 0.41), while epinephrine (OR 3.56) and surfactant use (OR 12.03) were significant risk indicators.
Conclusions:
- The restrictive intubation policy resulted in high survival but a notable rate of air leaks.
- Air leaks were linked to adverse outcomes, including death and severe intraventricular hemorrhage.
- Prenatal steroids demonstrated a protective effect; epinephrine and surfactant use were identified as risk indicators.
Objectives:
To identify perinatal risk indicators for air leaks in preterm infants treated with a policy of restrictive use of endotracheal intubation based on sustained inflations followed by noninvasive ventilation in the delivery room.
Methods:
Perinatal variables and variables of respiratory support in the delivery room were analyzed retrospectively in a cohort of 297 inborn preterm infants with a gestational age <29 weeks born in 2005-2009 in a tertiary care center with respect to their associations with air leaks. Multivariate logistic regression analysis was performed to analyze independent risk indicators.
Results:
Gestational age was 26 weeks + 0 days (22+3 to 28+6), birth weight was 790 g (265-1,660) and 270/297 survived (91.0%). A total of 63 (21.2%) developed air leaks, 32 (10.8%) pneumothorax, 44 (14.8%) pulmonary interstitial emphysema, and 1 (0.3%) pneumopericardium. The infants with air leaks had a higher risk of death (p < 0.01) and of intraventricular hemorrhage grade 3/4 (p < 0.05). Air leaks were associated with less use of prenatal steroids (p < 0.01), more frequent use of cardiac compressions (p < 0.01), use of a pressure of 30 cm H2O for sustained inflations (p < 0.05), and intubation in the delivery room (p < 0.01). After multivariate logistic regression only prenatal steroids (OR 0.41, 0.20-0.85), epinephrine (OR 3.56, 1.55-8.15) and surfactant use (OR 12.03, 3.39-42.72) remained significant.
Conclusions:
Our approach resulted in a high survival rate but was associated with a substantial rate of air leaks, which were associated with death and severe intraventricular hemorrhage. Prenatal steroids were protective, and epinephrine and surfactant use were significant risk indicators, whereas the use of sustained inflations was not a risk factor.
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