JOURNAL CLUB · ARTICLE OF THE WEEK
Air or 30% oxygen at birth for moderate-to-late preterm babies (AIROPLANE)
Peart SR, Manley BJ, Cheong JLY, et al; for the AIROPLANE Trial Investigators. JAMA. 2026. doi:10.1001/jama.2026.14201. An unblinded, cluster randomised crossover trial.
NO DIFFERENCE
AT BIRTH
No difference in the primary outcome
Ongoing respiratory support on leaving the delivery room was 72.6% (30%) vs 73.3% (air). Risk difference -0.83% (95% CI -4.33 to 2.67).
Consistent across subgroups
No difference by gestation (32-33 vs 34-35 weeks) or by tertiary vs non-tertiary centre.
Less escalation with 30% (exploratory)
Babies started on 30% were less likely to receive higher-level delivery-room support (PPV, intubation or supraglottic airway, compressions or adrenaline); proportional OR 0.70 (95% CI 0.52-0.95).
Less intubation afterwards (exploratory)
Endotracheal ventilation beyond the delivery room was 6.4% vs 9.3% (RR 0.69, 95% CI 0.47-0.91).
The verdict
For 32-35 week babies, starting with air or 30% made no difference to the main outcome. The signals of less escalation with 30% are exploratory and not adjusted for multiple testing.
WHY THIS MATTERS
- Moderate-to-late preterm babies (32-36 weeks) are about 85% of all preterm births but are barely represented in resuscitation trials
- Guidelines are clear at the extremes (air at 35+ weeks; at least 30% below 32 weeks) but say there is insufficient evidence for 32-35 weeks
- Practice varies widely: in one international survey 42% started with air, 35% with 30%, the rest higher
- Too much oxygen at birth generates free radicals and can harm; too little may slow the transition
- A large, pragmatic Australian trial gives a locally relevant answer
STRENGTHS
- Large (1818 babies) and pragmatic, across 26 diverse Australian sites
- Directly answers a gap the guidelines label insufficient evidence
- Cluster crossover design: each site used both strategies, reducing between-site imbalance
- Included regional, non-tertiary, public and private hospitals, so broadly generalisable
- A waiver of consent captured a representative population, not only consented babies
LIMITATIONS
- Unblinded - clinicians knew the starting oxygen and may have escalated care differently
- The two levels are close (21% vs 30%) and only applied for the first 3 minutes; most babies in both groups had their FiO2 escalated anyway
- The primary outcome (support on leaving the delivery room) is somewhat subjective in a low-risk population
- No physiological data, no timing of oxygen changes, and no follow-up beyond discharge
- The secondary-outcome signals were not adjusted for multiple testing, so they are hypothesis-generating only
Practice implications
Most babies who need help at birth in a special care nursery are moderate-to-late preterm, so this trial speaks directly to them. The headline is reassuring: for babies born at 32-35 weeks, starting delivery-room support with air (21%) or 30% oxygen made no difference to whether they still needed respiratory support on leaving the delivery room. Follow your local and ANZCOR guidance for the starting oxygen, then titrate promptly to the target saturations - that titration matters more than the exact starting point. The exploratory signals that 30% led to a little less escalation (less PPV, less intubation) are interesting but not definitive, and should not on their own change practice. Keep the basics excellent: a good mask seal and effective inflations, a pulse oximeter with saturation targets, and early escalation when a baby is not responding.
What starting oxygen does your unit use for a 33-week baby, and why?
How much does the starting FiO2 matter compared with how quickly you titrate to target saturations?
How should we weigh an exploratory signal (less escalation with 30%) against a neutral primary outcome?
Would blinding have been feasible, or worthwhile, in a delivery-room oxygen trial?
JAMA 2026ATTENDING A BIRTH
The Hub pageAIR vs OXYGEN
Resair 2 & landmark trialsJOURNAL CLUB
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Take-home message: AIROPLANE, a large pragmatic Australian trial, asked whether babies born at 32-35 weeks should start delivery-room support with air or 30% oxygen. There was no difference in the main outcome (ongoing respiratory support on leaving the delivery room; about 73% in both groups). Exploratory findings hinted at slightly less escalation with 30%, but these are not definitive. For now, use your local and ANZCOR starting oxygen and focus on prompt titration to target saturations and effective breathing support.
For educational purposes only. Journal club appraisal - figures paraphrased from the published trial; read the full article for complete data. Always align practice to your local guidelines.