DOI: 10.1002/ppul.26957 ISSN: 8755-6863

Inspired oxygen fraction thresholds to accurately predict surfactant administration in neonatal RDS is gestational age strata: A pragmatic, multi‐center study

Francesco Raimondi, Pasquale Dolce, Claudio Veropalumbo, Enrico Sierchio, Iuri Corsini, Fabio Meneghin, Silvia Lama, Roberto Raschetti, Silvia Varano, Alessandro Perri, Luca Bonadies, Almudena Alonso Ojembarrena, Javier Rodriguez Fanjul, Rebeca Gregorio Hernandez, Lorena Rodeño Fernandez, Peter G. Davis, Letizia Capasso,
  • Pulmonary and Respiratory Medicine
  • Pediatrics, Perinatology and Child Health



Current international guidelines on neonatal respiratory distress syndrome (RDS) recommend continuous positive airway pressure (CPAP) stabilization as primary treatment. Some guidelines recommend surfactant replacement for babies requiring FiO2 > 0.3 regardless of gestational age (GA). We explore the accuracy of alternative inspired oxygen fraction (FiO2) thresholds as early predictors of surfactant replacement in babies stratified by GA.

Study Design

Pragmatic, observational study in 12 Italian and Spanish neonatal intensive care units. This is a secondary analysis of data from two cohorts of preterm babies with RDS, stratified by GA (25°− 276; 28°−306; 31°−336) and stabilized on CPAP. FiO2 was collected soon after stabilization and its accuracy to predict subsequent surfactant administration by a rigorously masked physician was assessed.


We enrolled 412 preterm infants. FiO2 was collected within 2 h of life of life. A cut off of FiO2 > 0.30 failed to identify 50.3% of infants who were later given surfactant by a masked physician. A FiO2 = 0.29 threshold improved sensitivity values to 0.85, 0.79, and 0.61 for the three GA ranges while maintaining specificity of ≥85%. A FiO2 = 0.26 threshold gave sensitivity = 0.83 specificity = 0.79 with GA dependent differences (250−276 sensitivity = 0.90 specificity = 0.80; 280−306 sensitivity = 0.84 specificity = 0.78; 310−336 sensitivity = 0.73 specificity = 0.80).


FiO2 is a GA dependent predictor of early surfactant administration. Its accuracy increases when used at lower levels than currently recommended by international guidelines (236 words).

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