High-frequency oscillatory ventilation with sigh breath increases pneumothorax in neonates born at 22-25 gestational...

High-frequency oscillatory ventilation (HFOV) is widely used in neonates with respiratory distress syndrome (RDS) to optimize lung recruitment while minimizing ventilator-induced lung injury. Sigh breaths have been incorporated into HFOV to improve alveolar recruitment in cases of atelectasis. However, the safety of this approach, particularly in extremely preterm neonates, remains unclear. This study aimed to evaluate whether the use of sigh breaths during HFOV increased the risk of developing tension pneumothorax within the first 96 h after birth in neonates born at 22-25 weeks of gestation with RDS.

This retrospective cohort study included neonates born at 22-25 weeks of gestation between 2014 and 2023 who required rescue HFOV within 4 h of birth due to respiratory acidosis. Among 66 eligible neonates, 2 were excluded due to congenital anomalies, leaving 64 included for analysis. The study population was categorized into three groups: (1) neonates with atelectasis who received sigh breaths (n = 16), (2) neonates with atelectasis who did not receive sigh breaths (n = 3), and (3) neonates without atelectasis who did not receive sigh breaths (n = 45). The primary outcome was the incidence of tension pneumothorax within 12-96 h post-birth.

Tension pneumothorax occurred in 10 neonates (15.6%). Bivariable analysis revealed a significant association between the use of sigh breaths and tension pneumothorax (p = 0.007). Firth's penalized logistic regression demonstrated that neonates with atelectasis who received sigh breaths had a significantly higher risk of developing tension pneumothorax (odds ratio = 5.5, 95% confidence interval: 1.2-23.9, p = 0.02) compared to those without atelectasis who did not receive sigh breaths. In contrast, no significant difference was observed between neonates with and without atelectasis who did not receive sigh breaths.

While sigh breaths during HFOV may facilitate alveolar recruitment in preterm neonates with atelectasis, their use appears to significantly increase the risk of tension pneumothorax. Given the vulnerability of extremely preterm lungs, caution is required when implementing sigh breaths in this population. Further prospective studies are needed to refine ventilation strategies and minimize complications in extremely preterm neonates.