PubMedThe Lancet. Child & adolescent health2026-06-05
Respiratory trajectories of infants born before 26 weeks of gestation from birth to discharge: an exploratory analysis of a randomised controlled trial.
Martinez Tugba Alarcon TA, Francis Kate L KL, Kamlin Omar O, Shalish Wissam W et al.
To survive, infants born before 26 weeks' gestation require respiratory assistance immediately after birth. However, the respiratory trajectories of these most preterm infants are not well delineated. We aimed to describe the early respiratory trajectories of infants born before 26 weeks' gestation who received surfactant during their initial neonatal intensive care admission.
This study was a post-hoc exploratory analysis of PLUSS, a randomised controlled trial comparing intratracheal budesonide mixed with surfactant versus surfactant alone. Infants were recruited from 21 neonatal intensive care units in Australia, New Zealand, Canada, and Singapore. Infants born before 28 weeks' gestation and aged less than 48 h were eligible if (1) they were mechanically ventilated, or (2) they were receiving non-invasive respiratory support and there was a clinical decision to treat with surfactant. For this analysis, only infants born before 26 weeks' gestation were included, and treatment and control groups were combined. We aimed to describe early respiratory trajectories, including the levels of respiratory support and oxygen administered during the first 14 days, and respiratory outcomes at 28 postnatal days and 36 weeks' and 40 weeks' postmenstrual age. The main in-hospital respiratory outcomes were the timing and success of the first extubation, the durations of respiratory support, including oxygen requirements, and outcomes at hospital discharge, such as duration of hospital stay and discharge home on oxygen. PLUSS is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000322336), and follow-up is ongoing.
Between Jan 4, 2018, and March 27, 2023, 1062 infants were recruited to the PLUSS trial, of whom 601 were born before 26 weeks' gestation. 131 (97%) of 135 infants born at 22-23 weeks' gestation were intubated at birth, compared with 163 (74%) of 220 infants born at 24 weeks and 157 (64%) of 246 infants born at 25 weeks. The median postnatal age at first extubation ranged from 15 days (IQR 8-26) in infants born at 22-23 weeks' gestation to 6 days (2-18) in those born at 24 weeks and 3 days (1-10) in those born at 25 weeks. 54 (66%) of 82 infants born at 22-23 weeks' gestation required reintubation, compared with 80 (51%) of 158 infants born at 24 weeks and 72 (38%) of 189 infants born at 25 weeks. The median duration of mechanical ventilation in infants who survived to 36 weeks' postmenstrual age was 36 days (IQR 23-49) in those born at 22-23 weeks' gestation, 26 days (14-39) in those born at 24 weeks, and 12 days (3-27) in those born at 25 weeks. At 40 weeks' postmenstrual age, nine (11%) of 83 surviving infants born at 22-23 weeks' gestation were discharged home, and 63 (85%) of 74 infants still in the hospital were receiving oxygen or respiratory support. By contrast, 36 (23%) of 160 surviving infants born at 24 weeks and 61 (30%) of 204 born at 25 weeks were discharged home, and 97 (78%) of 124 in-hospital infants born at 24 weeks and 79 (55%) of 143 in-hospital infants born at 25 weeks required oxygen or respiratory support.
The most preterm infants born at the margins of viability require intensive and prolonged respiratory support. Knowledge of the respiratory trajectories in surfactant-treated infants born before 26 weeks' gestation could assist clinicians in family consultations while also guiding future randomised controlled trials.
National Health and Medical Research Council, Australia; Chiesi Farmaceutici.
