We recently welcomed many extreme preterms (23 24 GA) with particularly complicated respiratory insufficiency. The initial management was ok but secondary degradation often led to intubation and finaly aggressive ventilation with HFO due to high oxygen dependancy. we're used to use NAVA or volume ventilation but these different modes didn't work for our last patients.

In the end steroids were attempted but not always successful.

Do you have a specific respiratory management in these gestational ages in case of secondary intubation in terms of ventilation mode, general prescriptions...?

Thank you for your help,

Hi, sorry to hear you are struggling with the extreme premature respiratory management.

What do you mean by 'initial management was ok'? I think the devil is in the details of initial respiratory management. Here are my thoughts below.

Some European practices have moved away from using non-invasive respiratory support as a first-line for these gestations as studies such as Epicure, SUPPORT and NRN subgroup analysis showed high NIV failure rates and worse outcomes for such babies.

Therefore, services are moving back towards elective intubation at the time of delivery and giving very early surfactant (to prevent potential atelectasis-induced injury with CPAP/BiPAP/NIPPV). Volume-targeted ventilation has also become an initial starting ventilation mode to prevent volume-related lung damage (European RDS consensus, Cochrane review 2017)

British association of perinatal medicine also included early hydrocortisone as an option for babies who are likely to have severe chronic lung disease due to emerging evidence https://www.bapm.org/resources/195-extreme-preterm-birth-a-framework-for-practice-2023

Early hydrocortisone should not be used with indomethacin due to significant increased risk of spontaneous gut perforation and there is a lack of long-term follow-up studies to assess its effect on neurodevelopment.

I would be interested to know what is your usual initial respiratory management strategy for 22-24 weeks gestations.

Hi,

There are several factors that influence the ventilation strategy we pursue, and it often differs from baby to baby. DCC is important and, in my view, crucial. For babies born at <25 weeks, we typically proceed with intubation after birth, ideally in the NICU rather than the delivery room, and administer early surfactant.

We prefer using the Dräger ventilator over other machines, as it’s dependable and allows for precise control. We use PC-AC with VG, targeting tidal volumes of 5–6 mL/kg, with a short inspiratory time and optimum PEEP. We don’t usually attempt extubation until at least day 3 of life, provided the clinical condition allows. Our philosophy is to let the baby “grow out of the tidal volume” rather than wean it too early.

We also consider prophylactic hydrocortisone, particularly in the context of extremely preterm birth and early ventilator dependence. Routine sedation is generally avoided, as it’s often associated with the need for inotropes and increased risk of intraventricular haemorrhage (IVH). Caffeine is given as early as possible, ideally within the first 30 minutes of life. We also prioritise initiating mother’s own milk within the first 6 hours, even if in small trophic volumes.

That said, this approach is different from the one we take in babies with evolving or established BPD, where the ventilation strategy changes significantly—and that’s probably a discussion for another time.

Best regards,

Hello Justinas, thank you for your very interesting answer.

When I say that the initial management was ok, I mean that whatever the ventilation mode (biPAP of invasive ventilation), the parameters were quite standard with no oxygenation difficulties. Most of the 23/24 GA newborns in our NICU were on mechanical ventilation either since the delivery room, or a few hours later. Surfactant instillation was made using LISA or in the tube.

We currently use prophylactic hydrocortisone for all infants born before 28 weeks GA.

What happened for our last patients is a secondary intubation, often during an infection with increasing ventilation needs, firts in volume targeted mode, then in HFO with very high mean pressures (such as 18 to 20 cmH20, more than we ever used). Despite the iduced chest overdistension, we didn't manage to decrease the pressure regimen.

My questions were: should we use NAVA right away? how to avoid high mean airway pressures and overdistension in HFO. Do you happen to use NO for these patients even without clear pulmonary hypertension in the US? Do you do catheter early ductus arteriosus closure (<15days) if large and if the medical treatment didn't work?

Dear colleagues,

I fully agree with the initial reflection. We are facing a population of premature infants that challenges established paradigms and forces us to be more analytical and less dogmatic. The heterogeneity of this group is such that generalizing or applying evidence from populations of a higher gestational age is, at the very least, risky.

The lack of a clear consensus, and the observation that world-renowned reference centers achieve excellent outcomes with disparate ventilation strategies, puts us in a complex yet interesting position. It pushes us toward what many have mentioned: the importance of benchmarking and, fundamentally, of building our own solid and measurable experience.

Faced with this reality, in our unit, we have opted for an approach based on prudence, accumulated experience, and, above all, on building our own evidence. I wanted to share our current protocol to help enrich this discussion:

Our approach is structured as follows:

1. Initial Management in the Delivery Room: We proceed with elective intubation in the delivery room to secure the airway and optimize the transition in a controlled manner.

2. First Phase of Ventilation (Day 1): We begin with Conventional Mechanical Ventilation (CMV) in SIMV mode with Pressure Support and Volume Guarantee (VG). This modality allows for a safe initial adaptation, letting us closely monitor lung mechanics and ensure a consistent tidal volume.

3. Transition to HFOV: Once the patient achieves satisfactory cardiorespiratory adaptation and we consider the most critical phase of the transition to be over, we proceed to switch them to High-Frequency Oscillatory Ventilation (HFOV), also with the Volume Guarantee (HFOV-VG) option. With this, we aim for a more lung-protective strategy for the subsequent phase.

This phased approach allows us to manage the initial transition with a modality that our team masters and feels confident with (CMV-VG), and then to capitalize on the benefits of HFOV once the patient is more stable.

We understand that this is "our" current path and it is under constant evaluation and analysis of our outcomes. We do not claim it to be the only valid one, but rather wish to contribute our experience to this much-needed discussion.

It would be extremely enriching to learn about the strategies being implemented by other units. What approaches are you following? Have you had different results with other ventilation protocols?

vafo vg preterm ingles.pdf

I think it would be helpful to first reach a shared understanding of the primary outcome we’re aiming for. In the case of babies at 22–24 weeks, I imagine survival is the initial focus, before considerations such as neurodevelopment and BPD become more prominent.

With regard to HFOV, adjusting the frequency (Hz) typically affects the tidal volume delivered. If VG is enabled, increasing the frequency—perhaps to reduce CO₂ clearance—might not have the intended effect, as the ventilator will compensate by increasing the amplitude to maintain the set tidal volume, up to the user-defined limit, and vice versa.

Cheers!