Airway and ventilation challenges in extremely preterm infants weighing ≤500 grams

Introduction Infants weighing ≤500 g at birth represent one of the most vulnerable neonatal populations, with respiratory disease remaining the leading cause of mortality. Despite the near-universal need for endotracheal intubation and prolonged invasive respiratory support, data describing airway management and respiratory complications in this population remain limited. Material and methods Retrospective observational study of infants with a birth weight ≤500 g born at BCNatal (January 2020–September 2025) who received active perinatal care. Respiratory management, intubation characteristics, tracheal intubation-associated adverse events (TIAEs), short- and long-term outcomes and causes of death were analyzed. Results Twenty-nine infants (22 females, 75.9%) with a median gestational age of 23.9 weeks (IQR 23.4–25.6) were included. Twenty-six (89.7%) required endotracheal intubation and 17 (58.6%) were intubated in the delivery room. Four infants (15.4%) experienced severe TIAEs, and seven (26.9%) had at least one unplanned extubation. Among survivors, respiratory morbidity was substantial, with bronchopulmonary dysplasia in 90.9%, postnatal steroids use in 72.7%, and home oxygen therapy in 54.5%. Overall mortality was 62.1% (18/29). Respiratory disease accounted for 66.7% of deaths (12/18), including five deaths directly attributable to airway management or invasive mechanical ventilation. Neurodevelopmental impairment was identified in 75% (6/8) of infants assessed at 24 months’ corrected age. Conclusions Infants weighing ≤500 g require almost universal early endotracheal intubation and prolonged respiratory support, with a high burden of respiratory morbidity and mortality. The observed rate of severe TIAEs highlights the need for standardized airway management protocols, dedicated training, specific devices and prospective multicenter studies to optimize respiratory care in this extremely vulnerable population.