Elsevier

The Journal of Pediatrics

Volume 216, January 2020, Pages 109-116.e1
The Journal of Pediatrics

Original Article
Predictors and Outcomes of Early Intubation in Infants Born at 28-36 Weeks of Gestation Receiving Noninvasive Respiratory Support

https://doi.org/10.1016/j.jpeds.2019.09.026Get rights and content

Objective

To identify predictors and outcomes of early intubation in preterm infants with respiratory distress, and predictors of need for brief respiratory support (≤1 day).

Study design

Secondary analysis of data from a randomized trial comparing nasal high-flow with continuous positive airway pressure as primary respiratory support in preterm infants born at 28-36 weeks of gestation. Intubation was assessed within 72 hours of randomization.

Results

There were 564 included infants with a mean (SD) gestational age of 32.0 (2.2) weeks and birth weight 1744 (589) g; 76 infants (13.5%) received early intubation. On multivariable analysis, lower gestational age and higher pre-randomization fraction of inspired oxygen (FiO2) predicted intubation. A test based on gestational age of <30 weeks and an FiO2 of ≥0.30 produced a likelihood ratio of 9.1. Intubation was associated with prolonged duration of respiratory support and supplemental oxygen, with pneumothorax and nasal trauma, and in infants born at <32 weeks of gestational, with bronchopulmonary dysplasia and patent ductus arteriosus requiring treatment. Greater gestational age and lower FiO2 predicted the need for ≤1 day of respiratory support. A test based on a gestational age of ≥34 weeks and an FiO2 of 0.21 produced a likelihood ratio of 4.7.

Conclusions

In preterm infants 28-36 week of gestation receiving primary noninvasive respiratory support, lower gestational age, and higher FiO2 predicted need for intubation within 72 hours. Intubation was associated with adverse respiratory outcomes. Greater gestational age and lower FiO2 predicted need for ≤1 day of respiratory support. It may be reasonable to defer the use of respiratory support in more mature infants with low FiO2 requirements.

Trial registration Australian New Zealand Clinical Trials Registry

ACTRN12613000303741.

Section snippets

Methods

Between 2013 and 2015 we performed the HIPSTER trial: an international, multicenter, randomized, noninferiority trial in preterm infants born at 28-36 weeks of gestation that compared nHF 6-8 L/min with CPAP 6-8 cm H2O as primary support for early respiratory distress.20 Infants were eligible if they were <24 hours old, had not previously received endotracheal ventilation or surfactant treatment, and the attending clinician had decided to commence or continue noninvasive support. Infants were

Results

All 564 infants included in the randomized trial were included in this analysis. The mean (SD) gestational age and birth weight of this cohort were 32.0 (2.2) weeks and 1744 (589) g, and 289 infants (51.2%) were very preterm. Antenatal glucocorticoids were administered to the mothers of 453 infants (80.6%), and 404 births (71.6%) were by cesarean delivery. The median age at randomization was 1.4 hours (IQR, 0.7-2.8 hours) and 323 infants (57.3%) had received CPAP treatment (median, 1.5 hours;

Discussion

In a cohort of preterm infants who participated in a large, multicenter RCT of primary noninvasive support, lower gestational age and higher pre-randomization FiO2 predicted the need for intubation and mechanical ventilation within 72 hours. Infants who were intubated spent a median of 6 days longer on respiratory support and 5 days longer on oxygen therapy, and were more likely to have a pneumothorax and nasal trauma. Very preterm infants who were intubated had a 6-fold increase in the risk of

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    Supported by he National Health and Medical Research Council (NHMRC), Australia (No. 1079089, 1060733, and 1153176). C.R. is supported by the Monash University Kathleen Tinsley Research Fellowship. B.M. is supported by a Medical Research Future Fund (Australia) Next Generation Clinical Researchers Career Development Fellowship (MRF1159225). L.O. is supported by a National Health and Medical Research Council (NHMRC) Career Development Fellowship (No. 1159444). P.D. and C.R. have received travel support from Fisher and Paykel. The other authors declare no conflicts of interest.

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