Impact of implementation of 2019 European respiratory distress syndrome guidelines on bronchopulmonary dysplasia in very preterm infants

Abstract

Objective To evaluate the impact of implementation of 2019 European consensus guidelines on management of respiratory distress syndrome (RDS) on the incidence of bronchopulmonary dysplasia (BPD). Method Retrospectively collect the clinical data of very preterm infants (VPIs) born before 32 gestational weeks from January 1st 2018 to December 31st 2021. VPIs are divided into control group and observation group according to their birth date before or after January 1st 2020 when the implementation of 2019 European RDS guidelines initiated. BPD is considered as primary outcome. The secondary outcomes include death, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC) and extrauterine growth restriction (EUGR). Statistically analyze all the data and compare the general characteristics, ventilation support, medication, nutrition and the outcomes between two groups. Results A total of 593 VPIs were enrolled, including 380 cases in control group and 213 cases in observation group. There were no statistic differences regarding to conception mode, gender ratio, gestational age, birth weight, delivery mode and Apgar score in 5th minute between two groups (p > 0.05). Compared with control group, observation group showed higher rate of antenatal corticosteroid therapy (75.1% vs 65.5%) and lower rate of admission hypothermia (16.0% vs 35.5%) (p < 0.05). The incidence of BPD for the whole cohort was 21.6% (128/593). Overall risks of BPD included birth weight less than 1,000g, gestational age less than 28 weeks, male infants, intensive resuscitation, fetal growth retardation, invasive mechanical ventilation, high fraction of inspired oxygen (FiO2) demand, hypercarbia, sepsis, surfactant demand, long-term sedation, hemodynamically significant patent ductus arteriosus (hsPDA) and extrauterine growth restriction. The improvement of ventilation management included lower rate of invasive ventilation (40.4% vs 50.0%), higher rate of volume guarantee (69.8% vs 15.3%), higher initial positive end expiratory pressure (PEEP) [6 (5, 6) vs 5 (5, 5) cmH2O] and higher rate of nasal intermittent positive pressure ventilation (NIPPV) (36.2% vs 5.6%). Compared with control group, observation group received higher initial dose of pulmonary surfactant [200 (160, 200) vs 170 (130, 200) mg/Kg], shorter antibiotic exposure time [13 (7, 23) vs 17 (9, 33) days], more breast milk (86.4% vs 70.3%) and earlier medication for hsPDA treatment [3 (3, 4) vs 8 (4, 11) days] (p < 0.05). As the primary outcome, the incidence of BPD was significantly decreased (16.9% vs 24.2%) (p < 0.05), along with lower EUGR rate (39.0% vs 59.7%), while there were no statistic differences regarding to other secondary outcomes, including mortality, IVH, PVL, ROP and NEC (p > 0.05). However, in the subgroups of infants less than 28 gestational weeks or infants less than 1,000g, the incidence of BPD was not significantly decreased (p > 0.05). Conclusions After implementation of 2019 European RDS guidelines, the overall incidence of BPD was significantly decreased in VPIs. Continuous quality improvement is still needed in order to decrease the incidence of BPD in smaller infants who are less than 28 gestational weeks or less than 1,000g.