Table 3 |.
Interventions to minimize lung injury in premature infants
| Intervention | Rationale | Level of evidence | Clinical implications | Refs |
|---|---|---|---|---|
| Caffeine | Reduced time on ventilator leading to less lung damage | High quality: large RCT with long-term follow-up | Recommended for use in extremely preterm infants at the doses used in the CAP trial | 174,175 |
| Ventilation (conventional, high-frequency oscillation or jet ventilation) | Volutrauma is an important pathophysiological mechanism | Moderate quality: despite many RCTs, evidence of a substantial benefit of one mode is lacking | BPD rates remain high in all trials, suggesting that establishing and maintaining skills with a chosen mode may be the most important factor | 256,257 |
| Less-invasive surfactant therapy | Avoids the risks of endotracheal intubation | Low quality: small RCTs, imprecise estimates of safety and efficacy | Very promising, but more research required | 166–168 |
| Vitamin A | Low levels seen in preterm infants; vitamin A required for normal lung growth | Moderate quality: meta-analysis suggests a small reduction in rates of death or BPD | Depends on local incidence of BPD; trade-off between the modest reduction in BPD and acceptability of intramuscular treatment | 261 |
| Targeting lower oxygen saturation levels throughout NICU stay | Avoidance of high oxygen levels may reduce BPD | High quality: individual patient data meta-analysis of five high-quality RCTs | Targeting higher oxygen saturations (91–95%) improves survival rates without increasing risk of BPD | 198 |
| Glucocorticoids | ||||
| Dexamethasone | Reduced inflammation allowing earlier extubation | Moderate quality: meta-analyses and meta-regression of numerous small trials | Low-dose, short courses that are useful for ventilated infants at highest risk of BPD | 259,260 |
| Hydrocortisone | Avoids adverse neurodevelopmental effects of dexamethasone | Moderate quality: small RCTs, imprecise estimates of safety and efficacy | Promising, but more research into neurodevelopmental outcomes is required | |
| With surfactant | Better distribution of steroids and reduced systemic effects | Low quality: small RCTs, imprecise estimates of safety and efficacy | Very promising, but more research required | 191 |
BPD, bronchopulmonary dysplasia; CAP, Caffeine for Apnea of Prematurity; RCT, randomized controlled trial.