Update on ventilatory management of extremely preterm infants-A Neonatal Intensive Care Unit perspective

Area of Science:

• Neonatology
• Pediatric Pulmonology
• Critical Care Medicine

Background:

• Extremely preterm infants (born before 28 weeks gestation) frequently experience respiratory distress syndrome (RDS).
• Ventilatory management is initiated at birth, involving critical decisions on respiratory support timing, oxygenation targets, and positive pressure support options.
• Traditional intubation and surfactant administration via endotracheal tube are being challenged by noninvasive support and newer thin catheter surfactant delivery methods.

Purpose of the Study:

• To review current evidence on ventilatory management strategies for extremely preterm infants with RDS.
• To compare different methods of respiratory support and surfactant administration.
• To discuss emerging techniques and post-discharge respiratory care.

Main Methods:

• Review of available data from randomized trials comparing different ventilatory modes and surfactant administration techniques.
• Analysis of outcomes such as survival free of bronchopulmonary dysplasia (BPD), mortality, and secondary complications.
• Consideration of evidence for volume-targeted versus pressure-limited ventilation and emerging techniques for positive end-expiratory pressure (PEEP) optimization.

Main Results:

• Comparing thin catheter surfactant delivery to endotracheal tube methods showed no significant difference in survival free of BPD.
• Randomized trials comparing conventional ventilation with high-frequency oscillatory ventilation did not reveal significant differences in meaningful outcomes.
• Volume-targeted ventilation is supported by strong evidence, reducing the combined risk of BPD or death compared to pressure-limited ventilation without increasing adverse events.

Conclusions:

• Volume-targeted ventilation is recommended over pressure-limited ventilation for preterm infants.
• While newer surfactant administration methods are evolving, evidence on their superiority over traditional methods is pending.
• Further research is needed for evidence-based guidelines on PEEP setting, with forced oscillation technique showing potential.
• Noninvasive ventilation strategies require careful consideration of clinical context, prematurity, disease severity, and staff expertise.
• Post-discharge respiratory care, including home oxygen and asthma-like symptom management, is crucial.