Late-preterm resuscitation: 30% or 21% oxygen to start

Design

Unblinded cluster-randomised crossover trial in 26 hospitals

Population

1,818 newborns at 32–35 weeks needing respiratory support within 3 minutes

Primary outcome

Ongoing respiratory support when leaving the delivery room

Effect

72.6% vs 73.3% (risk difference −0.83, 95% CI −4.33 to 2.67)

The best starting oxygen concentration for resuscitating babies born at 32–35 weeks has not been known. AIROPLANE randomised 26 Australian maternity hospitals — tertiary and non-tertiary, metropolitan and regional — to start delivery-room respiratory support with 30% or 21% oxygen for the first three minutes, then crossed them over halfway. It enrolled 1,818 newborns, mean gestation 34 weeks.

The primary outcome — still on respiratory support when leaving the delivery room — did not differ (72.6% with 30% vs 73.3% with 21%; risk difference −0.83 points, 95% CI −4.33 to 2.67). Two of 12 secondary outcomes favoured 30%: less escalation of delivery-room support, including positive pressure ventilation, airway ventilation and compressions or adrenaline (proportional OR 0.70, 95% CI 0.52–0.95), and less endotracheal ventilation after leaving the delivery room (6.4% vs 9.3%; RR 0.69).

For those resuscitating late-preterm babies, either starting concentration is reasonable, with titration to saturation targets as usual. The secondary results lean towards 30%, but secondary outcomes in an unblinded trial are hypothesis-generating. Follow your unit's resuscitation guideline, which may change as these results are weighed.

• Either 21% or 30% oxygen is a reasonable start for babies born at 32–35 weeks.
• Titrate oxygen to pre-ductal saturation targets in the first minutes, whatever the start.
• Focus first on effective ventilation; oxygen concentration is secondary to it.
• Follow your unit's neonatal resuscitation guideline until it is updated.
• Fit pre-ductal oximetry early so titration is possible.

Why it matters

A large pragmatic trial in ordinary hospitals found no primary difference, with secondary signals that may shift guidance towards 30%.

Don't overread it

The escalation and intubation benefits are secondary outcomes in an unblinded trial and need confirmation.

The statistics, in plain English

The risk difference of −0.83 points with an interval of −4.33 to 2.67 rules out a large effect on the primary outcome. A proportional odds ratio of 0.70 means babies started on 30% were less likely to move up the ladder of resuscitation interventions.

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