Starting at 30% or 21% oxygen made no difference to the primary outcome in late-preterm resuscitation

Design

Unblinded cluster randomised crossover trial

Population

1,818 neonates born at 32–35 weeks needing respiratory support within 3 minutes, at 26 Australian maternity hospitals

Primary outcome

Ongoing respiratory support when leaving the delivery room

Effect

72.6% (FiO₂ 0.30) vs 73.3% (FiO₂ 0.21); risk difference −0.83 percentage points (95% CI −4.33 to 2.67)

AIROPLANE was a cluster randomised crossover trial across 26 Australian maternity hospitals — tertiary and non-tertiary, metropolitan and regional, public and private. Every infant born at 32 to 35 weeks without major anomalies who needed respiratory support within three minutes of birth was enrolled under a consent waiver, 1,818 in total. Sites began resuscitation at either 30% or 21% inspired oxygen and crossed over halfway through.

The primary outcome, still receiving respiratory support on leaving the delivery room, occurred in 72.6% at 30% oxygen and 73.3% at 21% (risk difference −0.83 percentage points, 95% CI −4.33 to 2.67). Ten of twelve secondary outcomes showed no difference either.

Two did. Infants started at 30% were less likely to escalate to higher levels of support in the delivery room (proportional odds ratio 0.70, 95% CI 0.52–0.95), and fewer needed endotracheal ventilation after leaving it (6.4% vs 9.3%; risk ratio 0.69, 0.47–0.91). Those are secondary findings from an unblinded trial and should be treated as hypothesis-generating rather than as a reason to change a starting setting — but they point the same way, which is worth noting for anyone who attends these deliveries.

• Follow your existing local resuscitation protocol for this gestation; this trial does not overturn it.
• Titrate to saturation targets from the first minute — the starting fraction matters less than what you do after it.
• Have a blender and pulse oximeter available at every delivery at this gestation, which is the actionable gap in many settings.
• Record the starting fraction of inspired oxygen in the delivery note so local practice can be audited.

Why it matters

A starting oxygen setting argued over for years turns out not to determine whether the baby leaves the delivery room on support.

Don't overread it

The escalation and intubation differences were secondary endpoints in an unblinded trial with twelve secondary comparisons.

The statistics, in plain English

The confidence interval for the primary outcome, −4.33 to +2.67 percentage points, is tight around zero: this is a genuine null result, not an underpowered one. The two positive secondary outcomes come from twelve comparisons, and with twelve tests one or two crossing significance by chance is expected — which is precisely why secondary endpoints do not change practice on their own.

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