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Original Investigation
July 6, 2021

Changes in Use of Respiratory Support for Preterm Infants in the US, 2008-2018

Author Affiliations
  • 1Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
  • 3Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
  • 4Mednax Center for Research, Education, Quality and Safety, Sunrise, Florida
  • 5Division of Neonatology, University of Alabama at Birmingham
  • 6Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 7Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
  • 8Center for Health Services Research, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 9Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center, Nashville, Tennessee
JAMA Pediatr. 2021;175(10):1017-1024. doi:10.1001/jamapediatrics.2021.1921
Key Points

Question  Has mechanical ventilation of preterm infants changed in response to increasing noninvasive ventilation use and increasing survival of infants at the limits of viability?

Findings  In this cohort study using 2 large US national data sets and including more than 1 million preterm infants, the use of mechanical ventilation in nonanomalous preterm infants in neonatal intensive care units decreased from 29.4% in 2008 to 18.5% in 2018. Nationally, these changes were associated with nearly 30 000 fewer infants receiving mechanical ventilation than expected during the study period.

Meaning  The findings of this study suggest that the use and duration of mechanical ventilation decreased significantly in preterm infants between 2008 and 2018.


Importance  In preterm infants, mechanical ventilation (MV) is associated with adverse pulmonary and neurodevelopmental outcomes. Multiple randomized clinical trials over the past 2 decades have shown the effectiveness of early noninvasive ventilation (NIV) in decreasing the use of MV in preterm infants. The epidemiologic factors associated with respiratory support in US preterm infants and any temporal changes after these trials is unknown.

Objective  To evaluate temporal changes in MV and noninvasive respiratory support in US preterm infants.

Design, Setting, and Participants  In a cohort design, 2 large national data sets (Pediatrix Clinical Data Warehouse for the clinical cohort and National Inpatient Sample for the national cohort) were used to collect data on preterm infants (<35 weeks’ gestation) without congenital anomalies who received active intensive care and were discharged home or died in the birth hospital from January 1, 2008, to December 31, 2018. Data analysis was conducted from December 10, 2019, to December 16, 2020.

Exposure  Discharge year.

Main Outcome and Measures  In the clinical cohort, detailed respiratory support data were generated, including days of MV and NIV modalities, and temporal trends were evaluated using multivariable modified Poisson or negative binomial regression models with discharge year as a continuous variable. In the national cohort, observed and expected national MV use were calculated.

Results  Among 259 311 infants (47.2% female) in 359 neonatal intensive care units in the clinical cohort, decreases were noted in the use (from 29.4% of infants in 2008 to 18.5% in 2018, relative risk for annual change, 0.96; 95% CI, 0.95-0.96) and duration (mean days, from 10.3 in 2008 to 9.7 in 2018; rate ratio for annual change, 0.98; 95% CI, 0.97-0.98) of MV. Noninvasive ventilation use increased from 57.9% of infants in 2008 to 67.4% in 2018 (adjusted relative risk for annual change, 1.02; 95% CI, 1.02-1.03), and mean NIV duration increased by 3.2 days (95% CI, 2.9-3.6 days). With increased use of continuous positive airway pressure and nasal intermittent positive-pressure ventilation as the main factors in the increase, the mean duration of respiratory support increased from 13.8 to 15.4 days (adjusted rate ratio for annual change, 1.03; 95% CI, 1.02-1.04) from 2008 to 2018. Among 1 169 441 infants in the national cohort, MV use decreased from 22.0% in 2008 to 18.5% in 2018, with an estimated 29 700 fewer ventilated infants and 142 000 fewer days of MV than expected during this period.

Conclusions and Relevance  These findings suggest that preterm respiratory support changed significantly from 2008 to 2018, with decreased use and duration of MV, increased use and duration of NIV, and an overall increase in respiratory support duration.

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