Higher PEEP May Improve Outcomes in Extremely Preterm Infants: Study
Germany: Researchers have found in a new study that among premature infants born before 32 weeks of gestation, using positive end-expiratory pressure (PEEP) of 10 cmH₂O at birth provided similar oxygenation at 5 minutes compared with the guideline-recommended 6 cmH₂O. However, infants receiving 6 cmH₂O PEEP had higher rates of intubation within 72 hours, as well as increased risks of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP).
These findings, published in BMJ's ADC Fetal and Neonatal Edition, suggest that higher initial PEEP (10 cmH₂O) may reduce respiratory complications and improve short-term outcomes in very preterm infants.
The optimal level of positive end-expiratory pressure (PEEP) during respiratory support immediately after birth remains uncertain for very preterm infants. Current delivery room guidelines commonly recommend a PEEP of 5–6 cmH₂O, but evidence supporting this recommendation is limited. To explore whether a higher PEEP level could improve neonatal outcomes, researchers led by Kriszta Molnar from the Department of Neonatology, University Children's Hospital, Tübingen University Hospital, Germany, compared outcomes before and after a hospital-wide change in delivery room practice.
The retrospective cohort study included 718 infants born before 32 weeks' gestation at the University Hospital Tübingen between 2015 and 2023. Following a 2019 protocol change, researchers compared outcomes between infants receiving an initial PEEP of 6 cmH₂O and those receiving 10 cmH₂O during the first 10 minutes after birth.
The primary outcome was oxygenation at five minutes, measured by the SpO₂/FiO₂ ratio. Secondary outcomes included respiratory interventions and major neonatal complications.
Key findings of the study include:
- Oxygenation at five minutes after birth was similar between infants receiving 10 cmH₂O and those receiving 6 cmH₂O PEEP.
- Infants in the low-PEEP group were more likely to require less-invasive surfactant administration.
- The duration of non-invasive respiratory support was longer among infants who received the lower PEEP level.
- Low-PEEP ventilation was associated with a significantly higher likelihood of intubation within the first 72 hours after birth.
- Infants managed with 6 cmH₂O PEEP also had higher risks of developing bronchopulmonary dysplasia and retinopathy of prematurity compared with those receiving 10 cmH₂O.
The findings suggest that a higher initial PEEP may improve lung recruitment without affecting early oxygenation while reducing the need for invasive respiratory support and the risk of prematurity-related complications.
The researchers noted that the single-center observational design cannot establish causality, and changes in neonatal care over time may have influenced the results.
They concluded that an initial PEEP of 10 cmH₂O may improve short- and long-term respiratory outcomes in infants born before 32 weeks' gestation, but larger randomized controlled trials are needed before it can be recommended in routine neonatal resuscitation guidelines.
Reference:
Molnar K, Broghammer J, Warth P, et al. High versus low PEEP in the delivery room: a preimplementation and postimplementation cohort study. Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 29 June 2026. doi: 10.1136/archdischild-2026-330466
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