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Carbon Dioxide Levels in Extremely Preterm Neonates Ventilated With High Frequency Jet Ventilation

Dimitrios Rallis^1,2, Danielle Ben-David¹, Kendra Woo¹

¹Prof. Rallis, Ms. Ben-David, Ms. Woo, Ms. Murphy, Ms. Robinson, Dr. Bernardini, Dr. Elisa, Dr. Elizabeth, and Prof. Christou are affiliated with the Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Respiratory Care

|April 8, 2026

Abstract

Background:

Close monitoring of carbon dioxide (CO₂) levels is crucial in extremely preterm neonates; however, a consensus on the optimal CO₂ thresholds is lacking. We aimed to evaluate the impact of P_aCO₂ levels during the first 24 h of life on the outcomes of extremely preterm neonates ventilated with first-intention high frequency jet ventilation (HFJV).

Methods:

We retrospectively examined neonates ≤26 weeks of gestational age who were ventilated with first-intention HFJV, during 2022-2024, comparing the lowest P_aCO₂, peak P_aCO₂, P_aCO₂ fluctuations, and P_aCO₂ deviation from the target (40-50 mm Hg) during the first 24 h of life between neonates who survived without severe intraventricular hemorrhage (IVH) and neonates who developed severe IVH or died.

Results:

Among 50 extremely preterm neonates of gestational age 24.3 ± 1.5 weeks and birthweight 656 ± 170 g, 33 (66%) survived without severe IVH. Neonates who survived without severe IVH were of greater gestational age (24.7 ± 1.3 vs 23.6 ± 1.5 weeks, P = .01) and birthweight (696 ± 159 vs 577 ± 167 g, P = .02), compared to neonates who developed severe IVH or died. The latter had significantly higher peak P_aCO₂ (66.7 ± 17.0 vs 54.6 ± 10.2 mm Hg, P = .006), P_aCO₂ fluctuations (30.8 ± 17.3 vs 16.6 ± 8.8 mm Hg, P = .001), and P_aCO₂ deviation from the target (20.0 ± 14.9 vs 9.7 ± 7.3 mm Hg, P = .003), compared to neonates who survived without severe IVH. A higher peak P_aCO₂, P_aCO₂ fluctuation, and P_aCO₂ deviation from the target were significantly associated with severe IVH, death, or severe IVH/death. A cutoff of a peak P_aCO₂ <65 mm Hg, P_aCO₂ fluctuation <25 mm Hg, and P_aCO₂ deviation <15 mm Hg from the target had the best sensitivity and specificity for survival, absence of severe IVH, and survival without severe IVH.

Conclusions:

In extremely preterm neonates ventilated with first-intention HFJV, maintaining peak P_aCO₂ of <65 mm Hg, P_aCO₂ fluctuations <25 mm Hg, and P_aCO₂ deviation from target <15 mm Hg was significantly associated with survival without severe IVH.

Keywords:

carbon dioxide high-frequency jet ventilation intracranial pathology intraventricular hemorrhage preterm

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