Respiratory management of extremely preterm neonates: Evidence generation and implementation by comparative effectiveness research (CER) using real world data (RWD) from a practice-based research network (PBRN)

Infants born extremely preterm before 29 weeks' gestational age face a myriad of potential challenges, many of which result from immature brain and lungs at birth. For example, extremely preterm infants have a 10% risk of mortality, 15% risk of severe brain injury, and 45% risk of bronchopulmonary dysplasia (chronic lung disease). In the first week of life, survival is the primary goal for an extremely preterm infant and often treatment results in a tube in the airway and mechanical ventilation to assist or replace spontaneous breathing. The transition of an infant from respiratory support to breathing on his or her own is difficult because there are multiple respiratory management strategies without evidence indicating which is optimal. Our proposal addresses two questions about respiratory management of extremely premature infants. First, we know that 90% of brain hemorrhages happen in the first 3 days following birth; therefore, if an infant born at less than 26 weeks' gestational age needs a tube placed in his or her airway in the first 3 days following birth, is there less brain injury and lung disease if the tube is left in the airway until the infant is at least 3 days old or if the tube is taken out as soon as possible? Second, in infants born at less than 29 weeks' gestational age who required mechanical breathing assistance does intermittent pressure that gives the infant a breath (nasal intermittent positive pressure ventilation) or continuous pressure that opens up the lungs (nasal continuous positive airway pressure) lead to similar risk of either re-placing a tube in the airway or bronchopulmonary dysplasia? Our studies will identify the best respiratory management practice for reducing the risk of severe brain injury and bronchopulmonary dysplasia in extremely preterm infants. The evidence we generate will be used to inform future practice guidelines for the respiratory management of extremely preterm infants across Canada.