370 - Variations in respiratory management of preterm neonates <29 weeks gestation: An international survey

Publication Number: 370.7049

Marc Beltempo, McGill University Faculty of Medicine and Health Sciences, Monreal, PQ, Canada; Dirk Bassler, University Hospital of Zurich, Zurich, Zurich, Switzerland; Gil Klinger, Schneider Children's Medical Center of Israel and Tel Aviv University, Ramat Hasharon, HaMerkaz, Israel; Kjell Helenius, University of Turku, Turku, Varsinais-Suomi, Finland; Maximo Vento, Instituto de Investigación Sanitaria La Fe, VALENCIA, Comunidad Valenciana, Spain; Malcolm Battin, Auckland City Hospitial, Auckland, Auckland, New Zealand; Satoshi Kusuda, Kyorin University, Taito, Tokyo, Japan; Liisa Lehtonen, University of Turku, Turku, Varsinais-Suomi, Finland; Mikael Norman, Karolinska Institutet, Stockholm, Stockholms Lan, Sweden; Mark Adams, University Hospital Zurich, Zurich, Zurich, Switzerland; José Maria De Andrade Lopes, Instituto Fernandes Figueira Fiocruz, Rio de Janeiro, Rio de Janeiro, Brazil; Tetsuya Isayama, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan; Kei Lui, University of New South Wales, Sydney, New South Wales, Australia; Brian Reichman, Sheba Medical Center, Ramat Gan, HaMerkaz, Israel; Prakesh S. Shah, Mount Sinai Hospital, Toronto, ON, Canada; Laura San Feliciano, Hospital Universitario de Salamanca, Salamanca, Castilla y Leon, Spain; Heloise Torchin, Université Paris Cité, PARIS, Ile-de-France, France; Cristina Tuoni, Azienda Ospedaliero Universitaria Pisana, Pisa, Toscana, Italy; Małgorzata Stokłosa, Clinical Provincial Hospital No2, University of Rzeszow, Rzeszow, Podkarpackie, Poland

Background: Variations in mortality and bronchopulmonary dysplasia rates among very preterm infants exist among regions, networks, and countries. One of the possible explanations of these differences is the variations in clinical practices.

Objective: To survey the variations in clinical practices for management of respiratory conditions in preterm neonates of < 29 weeks’ gestation among 12 population-based national or regional neonatal networks participating in the International Network for Evaluating Outcomes in Neonates (iNeo).

Design/Methods: Online pre-piloted questionnaires were sent to the directors or representatives of 608 NICU’s participating in Australia/New-Zealand (ANZNN n= 30), Brazil (BZ=20), Canada (CNN n=32), Finland (FinMBR n=5), France (FR, n=70), Israel (INN n=26), Japan (NRNJ n=292), Poland (PL, n=56), Spain (SEN1500 n=55), Sweden (SNQ n=9), Switzerland (SwissNeoNet n=9), and Tuscany, Italy (TuscanNN n=4). The responses were based on practices in 2023.

Results: Overall, 383/608 units (63%) responded. The survey response varied from 37-100% among participating networks. The majority of responders indicated tolerating a maximum FiO2 of 30-49% before intubating (44-100% of units within networks). Maximum CPAP pressure tolerated before intubation was between 6-8 cm of H2O (50-100%). Most common initial mode of ventilation was synchronized IPPV (volume targeted between 0-80% and pressure controlled between 0-76% of units within networks; Table 1). The most common respiratory strategies for spontaneous breathing preterm infants who are on CPAP and continue to be in respiratory distress within 48 hours after birth in less than 40% oxygen based on gestational age are reported in Table 2. Majority of units will mechanically ventilate infants 23-24 weeks but practice for 25-26 weeks showed marked variability. The use of LISA/MIST for preterm infants with spontaneous breathing who are on CPAP and continue to be in respiratory distress within 48 hours after birth in less than 40% oxygen varied between 0 and 37% of units within networks and increased with GA. Most units do not use non-invasive NAVA for preterm infants < 29 weeks in their unit (0-40% of units within networks).

Conclusion(s): There were marked variations in respiratory management of very preterm infants between countries. Further collaboration and exploration are needed to better understand the association of these variations in practice with variations in rates of mortality and bronchopulmonary dysplasia.

Table 1. Respiratory management of infants born at < 29 weeks gestation in participating networks (% of units) 383/608
All numbers are percentage of units within each network. ANZNN = Australian and New Zealand Neonatal Network; BZ = Brazil; CNN = Canadian Neonatal Network; FinMBR = Finnish Medical Birth Register; FR = France; INN = Israel Neonatal Network; NRNJ = Neonatal Research Network of Japan; PL = Poland; SEN1500 = Spanish Neonatal Network; SNQ = Swedish Neonatal Quality Register; SwissNeoNet = Swiss Neonatal Network; TuscanNN = Tuscan Neonatal Network; FiO2 = Fraction of inspired oxygen, CPAP = continuous positive airway pressure, HFOV = high frequency oscillatory ventilation, HFJV = high frequency jet ventilation, IPPV = intermittent positive airway pressure ventilation, NAVA = neurally adjusted ventilator assist

Table 2. Most common respiratory strategy for spontaneous breathing preterm infants who are on CPAP and continue to be in respiratory distress within 48 hours after birth in < 40% oxygen by GA (% of units)
All numbers are percentage of units within each network. ANZNN = Australian and New Zealand Neonatal Network; BZ = Brazil; CNN = Canadian Neonatal Network; FinMBR = Finnish Medical Birth Register; FR = France; INN = Israel Neonatal Network; NRNJ = Neonatal Research Network of Japan; PL = Poland; SEN1500 = Spanish Neonatal Network; SNQ = Swedish Neonatal Quality Register; SwissNeoNet = Swiss Neonatal Network; TuscanNN = Tuscan Neonatal Network; CPAP = Continuous positive airway pressure, NIPPV = Non-invasive positive pressure ventilation; LISA: Less invasive surfactant administration