Adverse outcomes associated with intubation in preterm infants in the delivery room setting

Abstract

Background

Initiation of non-invasive ventilation (NIV) rather than delivery-room (DR) intubation reduces lung injury and bronchopulmonary dysplasia (BPD) in premature babies.

Methods

We performed a retrospective cohort study of infants born at 23 + 0 to <32 + 0 weeks’ gestation at a single tertiary centre (St George’s Hospital) from 2017 to 2024, excluding major congenital anomalies. Clinical data were extracted from BadgerNet and Cerner. Temporal trends in DR intubation and associations with neonatal outcomes were examined using univariable and multivariable analyses.

Results

A total of 717 infants were included. DR intubation rates declined from 66.3% in 2017 to 27.5% in 2024 (p < 0.001), with the large changes in infants >26 + 0 weeks’ gestation and >500g birthweight. Compared with non-intubated infants, those intubated in the DR were of lower gestational age, lower birthweight, and were less likely to be from multiple pregnancies. DR intubation was associated with higher rates of intubation at 24 h and 7 days, oxygen dependency at 28 days and at discharge, as well as BPD, IVH, death, and longer durations of invasive and non-invasive ventilation. After adjustment, DR intubation remained independently associated with intubation at 24 h and 7 days, oxygen dependency at 28 days and at discharge, BPD, IVH, death, and longer invasive (+6.56 days) and non-invasive ventilation (+7.42 days), but not with severe BPD, ROP, or length of stay.

Conclusion

Preterm infants offered NIV from birth had improved respiratory outcomes. DR intubation rates fell substantially over the study period, particularly in infants 26 + 0 to <32 + 0 weeks’ gestation and birthweight ≥500g. Although DR intubation likely reflects baseline immaturity and vulnerability, it remained independently associated with several adverse neonatal outcomes, supporting ongoing efforts to avoid unnecessary early invasive ventilation where feasible.