• Haresh Kirpalani, Sarah J Ratcliffe, Martin Keszler, Peter G Davis, Elizabeth E Foglia, Arjan Te Pas, Melissa Fernando, Aasma Chaudhary, Russell Localio, Anton H van Kaam, Wes Onland, Louise S Owen, Georg M Schmölzer, Anup Katheria, Helmut Hummler, Gianluca Lista, Soraya Abbasi, Daniel Klotz, Burkhard Simma, Vinay Nadkarni, Francis R Poulain, Steven M Donn, Han-Suk Kim, Won Soon Park, Claudia Cadet, Juin Yee Kong, Alexandra Smith, Ursula Guillen, Helen G Liley, Andrew O Hopper, Masanori Tamura, and SAIL Site Investigators.
• Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
• JAMA. 2019 Mar 26; 321 (12): 1165-1175.

ImportancePreterm infants must establish regular respirations at delivery. Sustained inflations may establish lung volume faster than short inflations.ObjectiveTo determine whether a ventilation strategy including sustained inflations, compared with standard intermittent positive pressure ventilation, reduces bronchopulmonary dysplasia (BPD) or death at 36 weeks' postmenstrual age without harm in extremely preterm infants.Design, Setting, And ParticipantsUnmasked, randomized clinical trial (August 2014 to September 2017, with follow-up to February 15, 2018) conducted in 18 neonatal intensive care units in 9 countries. Preterm infants 23 to 26 weeks' gestational age requiring resuscitation with inadequate respiratory effort or bradycardia were enrolled. Planned enrollment was 600 infants. The trial was stopped after enrolling 426 infants, following a prespecified review of adverse outcomes.InterventionsThe experimental intervention was up to 2 sustained inflations at maximal peak pressure of 25 cm H2O for 15 seconds using a T-piece and mask (n = 215); standard resuscitation was intermittent positive pressure ventilation (n = 211).Main Outcome And MeasuresThe primary outcome was the rate of BPD or death at 36 weeks' postmenstrual age. There were 27 prespecified secondary efficacy outcomes and 7 safety outcomes, including death at less than 48 hours.ResultsAmong 460 infants randomized (mean [SD] gestational age, 25.30 [0.97] weeks; 50.2% female), 426 infants (92.6%) completed the trial. In the sustained inflation group, 137 infants (63.7%) died or survived with BPD vs 125 infants (59.2%) in the standard resuscitation group (adjusted risk difference [aRD], 4.7% [95% CI, -3.8% to 13.1%]; P = .29). Death at less than 48 hours of age occurred in 16 infants (7.4%) in the sustained inflation group vs 3 infants (1.4%) in the standard resuscitation group (aRD, 5.6% [95% CI, 2.1% to 9.1%]; P = .002). Blinded adjudication detected an imbalance of rates of early death possibly attributable to resuscitation (sustained inflation: 11/16; standard resuscitation: 1/3). Of 27 secondary efficacy outcomes assessed by 36 weeks' postmenstrual age, 26 showed no significant difference between groups.Conclusions And RelevanceAmong extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks' postmenstrual age. These findings do not support the use of ventilation with sustained inflations among extremely preterm infants, although early termination of the trial limits definitive conclusions.Trial Registrationclinicaltrials.gov Identifier: NCT02139800.

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