High versus low PEEP in the delivery room: a preimplementation and postimplementation cohort study

Objective The optimal positive end-expiratory pressure (PEEP) to aerate the preterm lung directly after birth is still unknown. We aimed to determine whether a PEEP of 10 vs 6 cmH 2 O in the first 10 min after birth influences short and long-term outcomes. Methods This retrospective preimplementation and postimplementation study analysed preterm infants with a gestational age (GA) <32 weeks born between 2015 and 2023 at the University Hospital Tübingen. The local protocol regarding initial PEEP level was changed in 2019, resulting in a high-PEEP (10 cmH 2 O) versus a low-PEEP (6 cmH 2 O) group. Results 718 infants with median GA of 29 weeks were included. There was no group difference in the primary outcome, that is, the SpO 2 /FiO 2 ratio at 5 min after birth. More infants exposed to low PEEP received less-invasive surfactant administration (151 (41%) vs 101 (29%), p<0.05) and had a longer duration of non-invasive ventilation (30 (8–46) vs 19 (6–43.5) days, p<0.05). Moreover, they had a higher risk of being intubated within 72 hours of birth (OR 1.7; 95% CI 1.07 to 2.66, p<0.05) and of developing bronchopulmonary dysplasia (OR 1.7; 95% CI 1.14 to 2.64, p<0.05) or retinopathy of prematurity (OR 1.8; 95% CI 1.17 to 2.79, p<0.05). Conclusion Applying a higher PEEP (10 cmH 2 O) postnatally might be beneficial in preventing short as well as long-term outcomes in preterm infants, but randomised controlled trials are needed to confirm this hypothesis.