This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Hypotheses: 1. Relative to infants managed with prophylactic/early surfactant and conventional ventilation, the use of early continuous positive air pressure (CPAP) and a permissive ventilatory strategy in infants of less than 28-weeks gestation with continuing CPAP in the Neonatal Intensive Care Unit (NICU) will result in an increased survival without bronchopulmonary dysplasia (BPD) at 36 weeks. 2. Relative to infants managed with a higher pulse oximetry (SpO2) range, the use of a lower SpO2 range (85-89%) will result in an increase in survival without the occurrence of threshold retinopathy of prematurity (ROP) and/or the need for surgical intervention. 3. The use of CPAP with a permissive ventilator strategy and/or a lower SpO2 range starting at birth in the delivery room will result in a decrease in: 1) mortality/neurodevelopment impairment at 18-22-months corrected age; 2) incidence of surfactant treatment; 3) duration of interventional therapies; and 4) subsequent developmental impairments. Goals: Positive end expiratory pressure (PEEP) has been shown to be of benefit in maintaining functional residual capacity. Although no formal recommendation has been made to date about maintaining PEEP in the delivery room setting, CPAP appears beneficial during cardiopulmonary resuscitation. Gregory et al in 1971 first demonstrated that the use of CPAP started at approximately 5.9 hrs (+12.4 hours) for their infants <1500 g at birth, improved oxygenation in newborn infants with respiratory distress; these observations were followed by prospective studies that demonstrated improved survival in premature infants treated with early CPAP. Premature infants who do not achieve a functional residual capacity are more likely to develop hyaline membrane disease requiring mechanical ventilation. CPAP may prevent the excessive consumption of surfactant in newborn infants with limited surfactant production. A review of prospective studies evaluating early (not delivery room) CPAP in the pre-surfactant, pre-antenatal steroid era suggested that early CPAP may improve survival in infants greater than 1500 g. Similarly, there is no definite recommendation or standard teaching regarding the level of oxygenation that should be maintained in extremely low birth weight (ELBW) infants. Oxygen supplementation has to be used liberally as ELBW infants frequently have desaturation episodes and thus wide saturation ranges are tolerated clinically. However, oxygen toxicity can result in increased risk for chronic lung disease (CLD), ROP and other disorders. Alternatively, oxygen restriction may impair neurodevelopment. The pulse oximeter (PO) is a newer technology that can be used to improve the control of oxygenation levels. There is great potential benefit to determining the oxygenation levels that prevents ROP and CLD, but does not result in neurodevelopmental impairment with a randomized controlled trial of levels of oxygen saturations on the high and low side of the currently utilized levels. However, there have been a very few prospective studies evaluating the benefit of higher versus lower levels of oxygenation in infants, especially for ELBW infants, none of which were performed during the acute illness. While retrospective cohort studies have suggested that the use of lower SpO2 ranges and adherence to strict nursery policies may result in a lower incidence of severe ROP, there is no current agreement on the accepted SpO2 ranges for managing the ELBW infant from birth. This study has been designed to determine if the incidence of BPD can be reduced in premature infants by using CPAP and a permissive ventilation strategy rather than automatic endotracheal intubation, surfactant administration, and conventional mechanical ventilation beginning in the delivery room. We also hope to determine if maintaining lower oxygen saturation in these infants will reduce the incidence of significant ROP.
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