TOPLINE

Among premature infants born before 32 weeks of gestation, positive end-expiratory pressure (PEEP) of 10 cmH₂O and the guideline-recommended PEEP of 6 cmH₂O produced similar oxygenation at 5 minutes after birth. However, PEEP of 6 cmH₂O was associated with higher odds of intubation within 72 hours of birth, bronchopulmonary dysplasia, and retinopathy of prematurity than PEEP of 10 cmH₂O.

METHODOLOGY

• Researchers conducted a retrospective cohort study at a single tertiary neonatal centre in Germany to evaluate outcomes among premature infants before and after a change in the PEEP protocol in the delivery room.
• The analysis included 718 premature infants born before 32 weeks of gestation (53.3% boys) between 2015 and 2023 who received either continuous positive airway pressure or positive pressure ventilation within 10 minutes of birth.
• Infants received either high PEEP (10 cmH₂O; before the protocol change) or low PEEP (6 cmH₂O; after the protocol change) in line with the change in current European Resuscitation Council guidance in November 2019.
• The primary outcome was the peripheral oxygen saturation/fraction of inspired oxygen (SpO₂/FiO₂) ratio at 5 minutes after birth, which was used as a surrogate parameter for functional residual capacity.
• Other prespecified outcomes included delivery room parameters such as vital signs, intubation, and surfactant use, as well as NICU outcomes such as duration of ventilation, bronchopulmonary dysplasia, and retinopathy of prematurity.

TAKEAWAY

• The SpO₂/FiO₂ ratio at 5 minutes after birth was comparable between high and low PEEP groups (2.9 vs 2.8; P = .61); infants in the high PEEP group required less positive pressure ventilation in the delivery room than those in the low PEEP group (66% vs 73%; P < .05).
• Infants in the low PEEP group more often received less invasive surfactant administration in the NICU (41% vs 29%) and required a longer duration of non-invasive ventilation (median, 30 vs 19 days; P < .05 for both) than those in the high PEEP group.
• Low PEEP was associated with approximately 70% higher odds of intubation within 72 hours of birth and bronchopulmonary dysplasia and about 80% higher odds of retinopathy of prematurity than high PEEP (P < .05 for all).
• High PEEP was not associated with an increased risk for air leaks, including pneumothorax, within the first 7 days after birth during NICU admission.

IN PRACTICE

"[The study] provides evidence for a possible beneficial effect of using a higher PEEP level for initial lung aeration," the authors wrote.

"RCTs [randomised controlled trials] aiming to identify the optimal PEEP to aerate the lung after birth are underway and may confirm or refute our findings," they added.

SOURCE

The study was led by Kriszta Molnar, University Children's Hospital, Tübingen University Hospital, Tübingen, Germany. It was published online on June 29, 2026, in Archives of Disease in Childhood - Fetal and Neonatal Edition.

LIMITATIONS

The retrospective design of the study limited causal inference and may have introduced residual confounding. The study excluded infants intubated within the first 5 minutes of birth, which may have introduced selection bias. Multiple secondary outcomes were analysed without adjustment for multiple comparisons, which increased the chance of a false-positive finding.

DISCLOSURES

Four authors reported receiving support through intramural grants from the University of Tübingen for this study. The authors reported having no relevant competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.