Background: There are significant international variations in chronic lung disease rates among very preterm infants yet there is little data on international variations in respiratory strategies. Objective: To evaluate practice variations in the respiratory management of extremely preterm infants born at < 29 weeks’ gestational age (GA) among 10 neonatal networks participating in the International Network for Evaluating Outcomes (iNeo) of Neonates collaboration. Methods: A web-based survey was sent to the representatives of 390 neonatal intensive care units from Australia/New Zealand, Canada, Finland, Illinois (USA), Israel, Japan, Spain, Sweden, Switzerland, and Tuscany (Italy). Responses were based on practices in 2015. Results: Overall, 321 of the 390 units responded (82%). The majority of units within networks (40–92%) mechanically ventilate infants born at 23–24 weeks’ GA on continuous positive airway pressure (CPAP) with 30–39% oxygen in respiratory distress within 48 h after birth, but the proportion of units that offer mechanical ventilation for infants born at 25–26 weeks’ GA at similar settings varied significantly (20–85% of units within networks). The most common respiratory strategy for infants born at 27–28 weeks’ GA on CPAP with 30–39% oxygen with respiratory distress within 48 h after birth used by units also varied significantly among networks: mechanical ventilation (0–60%), CPAP (3–82%), intubation and surfactant administration with immediate extubation (0–75%), and less invasive surfactant administration (0–68%). Conclusions: There are marked variations but also similarities in respiratory management of extremely preterm infants between networks. Further collaboration and exploration is needed to better understand the association of these variations in practice with pulmonary outcomes.

Stoll BJ, Hansen NI, Bell EF, Walsh MC, Carlo WA, Shankaran S, Laptook AR, Sanchez PJ, Van Meurs KP, Wyckoff M, Das A, Hale EC, Ball MB, Newman NS, Schibler K, Poindexter BB, Kennedy KA, Cotten CM, Watterberg KL, D’Angio CT, DeMauro SB, Truog WE, Devaskar U, Higgins RD; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network: Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993–2012. JAMA 2015; 314: 1039–1051.
Isayama T, Lee SK, Yang J, Lee D, Daspal S, Dunn M, Shah PS: Revisiting the definition of bronchopulmonary dysplasia: effect of changing panoply of respiratory support for preterm neonates. JAMA Pediatr 2017; 171: 271–279.
Schmidt B, Asztalos EV, Roberts RS, Robertson CM, Sauve RS, Whitfield MF: Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy on the outcome of extremely low-birth-weight infants at 18 months: results from the trial of indomethacin prophylaxis in preterms. JAMA 2003; 289: 1124–1129.
Jensen EA, Foglia EE, Schmidt B: Evidence-based pharmacologic therapies for prevention of bronchopulmonary dysplasia: appli-cation of the grading of recommendations assessment, development, and evaluation methodology. Clin Perinatol 2015; 42: 755–779.
Shetty S, Greenough A: Neonatal ventilation strategies and long-term respiratory outcomes. Early Hum Dev 2014; 90: 735–739.
Lee SK, Shah PS, Singhal N, Aziz K, Synnes A, McMillan D, Seshia MM, Canadian EPIQ Study Group: Association of a quality improvement program with neonatal outcomes in extremely preterm infants: a prospective cohort study. CMAJ 2014; 186:E485–E494.
Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL: European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2016 Update. Neonatology 2017; 111: 107–125.
Jobe AH: Mechanisms of lung injury and bronchopulmonary dysplasia. Am J Perinatol 2016; 33: 1076–1078.
Shah PS, Lui K, Sjors G, Mirea L, Reichman B, Adams M, Modi N, Darlow BA, Kusuda S, San Feliciano L, Yang J, Hakansson S, Mori R, Bassler D, Figueras-Aloy J, Lee SK: Neonatal outcomes of very low birth weight and very preterm neonates: an international comparison. J Pediatr 2016; 177: 144–152.e146.
Rysavy MA, Li L, Bell EF, Das A, Hintz SR, Stoll BJ, Vohr BR, Carlo WA, Shankaran S, Walsh MC, Tyson JE, Cotten CM, Smith PB, Murray JC, Colaizy TT, Brumbaugh JE, Higgins RD: Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015; 372: 1801–1811.
Shah PS, Lee SK, Lui K, Sjors G, Mori R, Reichman B, Hakansson S, Feliciano LS, Modi N, Adams M, Darlow B, Fujimura M, Kusuda S, Haslam R, Mirea L: The International Network for Evaluating Outcomes of very low birth weight, very preterm neonates (iNeo): a protocol for collaborative comparisons of international health services for quality improvement in neonatal care. BMC Pediatr 2014; 14: 110.
Eysenbach G: Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004; 6:e34.
Choi BC, Pak AW: A catalog of biases in questionnaires. Prev Chronic Dis 2005; 2:A13.
Mukerji A, Shah PS, Shivananda S, Yee W, Read B, Minski J, Alvaro R, Fusch C: Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units. Acta Paediatr 2017; 106: 387–393.
Gagliardi L, Tagliabue P, Bellu R, Corchia C, Mosca F, Zanini R: Survey of neonatal respiratory support use in very preterm infants in Italy. J Matern Fetal Neonatal Med 2012; 25(suppl 3): 1–5.
Sakonidou S, Dhaliwal J: The management of neonatal respiratory distress syndrome in preterm infants (European Consensus Guidelines – 2013 update). Arch Dis Child Educ Pract Ed 2015; 100: 257–259.
Polin RA, Carlo WA: Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics 2014; 133: 156–163.
Klotz D, Porcaro U, Fleck T, Fuchs H: European perspective on less invasive surfactant administration – a survey. Eur J Pediatr 2017; 176: 147–154.
Heiring C, Jonsson B, Andersson S, Bjorklund LJ: Survey shows large differences between the Nordic countries in the use of less invasive surfactant administration. Acta Paediatr 2017; 106: 382–386.
Gopel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C, Siegel J, Avenarius S, von der Wense A, Vochem M, Groneck P, Weller U, Moller J, Hartel C, Haller S, Roth B, Herting E: Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011; 378: 1627–1634.
Subramaniam P, Ho JJ, Davis PG: Prophylactic nasal continuous positive airway pressure for preventing morbidity and mortality in very preterm infants. Cochrane Database Syst Rev 2016; 6:CD001243.
Stevens TP, Harrington EW, Blennow M, Soll RF: Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2007; 4:CD003063.
Peng W, Zhu H, Shi H, Liu E: Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2014; 99:F158–F165.
Dani C, Bresci C, Lista G, Martano C, Messina F, Migliori C, Vento G: Neonatal respiratory support strategies in the intensive care unit: an Italian survey. Eur J Pediatr 2013; 172: 331–336.
Wielenga JM, van den Hoogen A, van Zanten HA, Helder O, Bol B, Blackwood B: Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in newborn infants. Cochrane Database Syst Rev 2016; 3:CD011106.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.