# Occurrence and prediction of clinical interventions during transfer of near-term and term infants with respiratory distress on CPAP. An observational study

Alexia Morel, Julien Baleine, Christophe Milesi, Maliha Badr, Arthur Gaudaire, Alexandra Deveze, Sylvain Paulhac, Charline Andrieu, Marion Palpacuer, Gilles Cambonie, et al.

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## ► To cite this version:

Alexia Morel, Julien Baleine, Christophe Milesi, Maliha Badr, Arthur Gaudaire, et al. Occurrence and prediction of clinical interventions during transfer of near-term and term infants with respiratory distress on CPAP. An observational study. Archives de Pédiatrie, 2025, 10.1016/j.arcped.2025.07.001. hal-05308194

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Submitted on 18 Feb 2026

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# Occurrence and prediction of clinical interventions during transfer of near-term and term infants with respiratory distress on CPAP. An observational study

Alexia Morel<fnref n="1" />, Julien Baleine<fnref n="1" />, Christophe Milesi<fnref n="1" />, Maliha Badr<fnref n="1" />, Arthur Gaudaire<fnref n="2" />, Alexandra Deveze<fnref n="1" />, Sylvain Paulhac<fnref n="1" />, Charline Andrieu<fnref n="1" />, Marion Palpacuer<fnref n="1" />, Gilles Cambonie<fnref n="3" />, Arthur Gavotto<fnref n="4" />

**Keywords:**

Late-preterm (near-term) infant; Newborn infant; Patient transfer; Respiratory distress.

* Correspondence author at.

Department of Neonatal Medicine, Pediatric Intensive Care, Neonatal and Pediatric Emergency Transport Service, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, 371 Avenue du Doyen Giraud, 34295, Montpellier cedex 5, France.

E-mail address:

a-gavotto@chu-montpellier.fr

(A. Gavotto).

<footnote n="1">¹ Department of Neonatal Medicine, Pediatric Intensive Care, Pediatric Emergency Transport Service, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, France.</footnote>

<footnote n="2">² Department of Neonatal Medicine, Pediatric Intensive Care, Pediatric Emergency Transport Service, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, France; PhyMedExp, University of Montpellier, CNRS, INSERM, Montpellier, France.</footnote>

<footnote n="3">³ Department of Neonatal Medicine, Pediatric Intensive Care, Pediatric Emergency Transport Service, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, France; Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France.</footnote>

<footnote n="4">⁴ Department of Neonatal Medicine, Pediatric Intensive Care, Pediatric Emergency Transport Service, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, France; PhyMedExp, University of Montpellier, CNRS, INSERM, Montpellier, France. Electronic address: a-gavotto@chu-montpellier.fr</footnote>
# Abstract

**Background:**

Neonatal respiratory distress (NRD) requiring continuous positive airway pressure (CPAP) is a common indication for inter-hospital transfer of late preterm and term neonates. The optimal composition of the inter-hospital team transfer - involving an advanced neonatal nurse and an ambulance driver or a complete team, which also includes a paediatrician - remains uncertain. Particularly when clinical interventions are required.

**Objectives:**

To assess the occurrence of clinical interventions necessitating a complete transport team during the inter-hospital transfer of neonates with NRD on CPAP. A secondary objective was to evaluate whether data provided to the transfer regulation centre predicted such interventions.

**Methods and setting:**

This retrospective observational study was conducted at the Paediatric Emergency Transport Service (PETS) of a level 3 maternity hospital between 2021 and 2023. A total of 110 infants ≥34 weeks' gestational age were included, all transported for NRD with CPAP (mean gestational age 37.6 ± 2.2 weeks, mean birth weight 3042±615 g). Clinical interventions recorded included intubation, surfactant administration, inhaled nitric oxide (iNO) administration, needle aspiration for pneumothorax, and prostaglandin E1 infusion. Complete team transport involved a paediatrician, an advanced neonatal nurse, and an ambulance driver.

**Results:**

Clinical interventions occurred in 11 cases (10%). Factors associated with the need for intervention included higher $FiO_2$ (71.4 ± 18.5% vs 28.3 ± 8.0%, p < 0.01), presence of pneumothorax (p < 0.01), and transfer from higher-level maternity hospitals (p < 0.01). The ROC curve for $FiO_2$ predicting intervention had an area of 0.99 (95% CI 0.97-1.01, p = 0.001), with a cut-off of >40% yielding 91% sensitivity, 98% specificity, 83% positive predictive value, and 99% negative predictive value.

**Conclusions:**

High oxygen dependency and the presence of pneumothorax are key indicators for mobilizing a complete transport team during the transfer of late preterm and term neonates with NRD on CPAP. Early identification of these factors could enhance team allocation and resource utilization.
# 1. Introduction

Neonatal respiratory distress (NRD) affects up to 7 % of infants born at term (≥ 37 weeks' gestational age (GA)), and the incidence can be higher than 10 % for those born near-term, i.e., at 34-36 weeks' GA [1-3]. In most cases, NRD may result from a transient failure of the mechanism that allows the lung to switch from fluid secretion to fluid absorption, a condition known as transient tachypnoea of the newborn [4]. Alternatively, NRD can result from surfactant deficiency or inhibition, as observed in meconium aspiration syndrome, pneumonia, and pulmonary haemorrhage, and can be associated with persistent pulmonary hypertension of the newborn (PPHN)[3,5].

First-line treatment of NRD is based on continuous positive airway pressure (CPAP). If CPAP fails, intubation may be necessary to provide invasive ventilation[6]. Depending on the cause and/or the context, additional treatments such as surfactant, antibiotics, or inhaled nitric oxide (iNO) may be required. Such management can only be provided in a type 2 or 3 neonatal unit, which may necessitate transferring the infant if these resources are not available at the birth site.

In France, these transfers are carried out by the Emergency Transport Service, ideally specialised in paediatrics, within the framework of a Paediatric Emergency Transport Service (PETS). Depending on the infant's medical history, the severity of illness, and the devices and medications required to support vital functions, the regulating physician who organises the transfer may decide to initiate either an inter-hospital transfer involving an advanced neonatal nurse and an ambulance driver or a medicalised inter-hospital transfer, which also includes a paediatrician. This decision has significant consequences, as mobilising a complete team renders it unavailable for simultaneous primary care intervention, which is its primary role. Reports from emergency transport services in the UK and USA highlight the potential for these inter-hospital transports to be conducted by advanced neonatal nurse practitioners[7,8].

The main objective of this study was to identify criteria for selecting the appropriate emergency transport team, i.e., a medicalized or a nursing transfer, in near-term and term newborns with NRD managed with CPAP.

# 2. Methods

## 2.1. Study population

This retrospective study was carried out in the PETS, Montpellier University Hospital Centre (France), from January 2021 to December 2023. All neonates ≥34 weeks' GA requiring inter-hospital transport for NRD supported with CPAP were considered.
The criteria for exclusion were: (i) Patients already intubated at the time of the transfer regulation centre call; (ii) NRD not supported with CPAP (e.g., support with high-flow nasal cannula); (iii) Post-natal age greater than 3 days; (iv) Situations where medicalized transfer is systematically required, such as NRD in the context of perinatal asphyxia or severe congenital anomaly; (v) Patients with incomplete data.

## 2.2. Regional plan for the organization of neonatal care

There are three types of maternity in France. In type 1, there is no individualized neonatal unit, and the usual care for newborns takes place in the maternity ward. In type 2, two types of neonatal units can be differentiated. Type 2a provides the newborn with care such as enteral feeding by gastric tube, perfusion or administration of medication by peripheral venous route, low-flow and low-concentration oxygen therapy, and hemodynamic and respiratory monitoring. Type 2b, or intermediate care unit, enables care such as parenteral nutrition via a central venous catheter, non-invasive ventilation and continuous monitoring of vital functions. A type 3 maternity includes a neonatal intensive care unit (NICU), without (3a), or with (3b), a local neonatal surgical team. The number of nurses per neonate in neonatal units is framed by the French perinatal decrees of 1998, i.e., stipulating one nurse for two neonates for type 3 beds, one nurse for three neonates for type 2b beds, and one nurse for six neonates for type 2a beds.

When healthcare professionals request inter-hospital transfer of a newborn for more intensive care (for example, from a type 2a neonatal unit to a type 2b or 3), they contact the transfer regulation centre attached to the nearest type 3 unit. The regulating physician requests a PETS team to transport the infant to the selected neonatal unit. There are 2 PETS in the East Occitanie region, but the PETS located at Montpellier University Hospital Centre is the only one able to provide transport 24 hours a day, 7 days a week, in an on-call system. The network of maternity wards linked to the PETS of Montpellier University Hospital Centre includes six type 1 maternities, eight type 2a maternities, one type 2b maternity and two type 3 maternities. Their distance and transport time to the destination centre, Montpellier University Hospital, are shown in **Supplementary Table S1**.

## 2.3. Data collected

Perinatal characteristics included multiple pregnancy, premature rupture of membranes, maternal hypertension, maternal diabetes, delivery mode, intrauterine growth restriction (IUGR) - defined as birthweight <10th percentile [9] -, macrosomia - defined as birthweight >97th percentile [9]-, birthweight, GA, sex, Apgar score, post-natal age the day of transfer, and initial maternity ward. Data on clinical interventions performed were collected, both at the initial maternity ward (supplemental oxygen with FiO2, peripheral venous catheter, umbilical venous catheter, nasogastric tube), and by the PETS of Montpellier University Hospital Centre, before or during transfer. The type of transport selected by the regulating physician, nursing transfer or medicalized transfer, was also recorded.
## 2.4. Outcomes

The primary outcome was the occurrence of a clinical intervention requiring a complete team, during the inter-hospital transport performed by the PETS of Montpellier University Hospital Centre. Such intervention was defined as the need for at least one of the following acts: intubation, surfactant administration, iNO administration, needle aspiration or chest tube placement for pneumothorax, prostaglandin E1 infusion for suspected duct-dependent congenital heart defect, or specific intervention for vital neurological or cardiocirculatory distress.

The secondary outcome was to assess whether the data provided by the initial maternity Hospital to the transfer regulation centre, at the request of inter-hospital transfer, were predictive of an intervention requiring a complete team.

## 2.5. Statistical analysis

Comparisons were conducted using the Fisher, chi-squared, Student, and Wilcoxon-Mann-Whitney tests, as appropriate. The predictive accuracy of the data provided to the transfer regulation centre was evaluated using sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristics (ROC) curve.

Statistical analysis was performed with EasyMedStat version 3.21.5 software (Paris, France).

*P* <0.05 was considered statistically significant.

## 2.6. Ethical considerations

Approval of this study was obtained from the institutional review board of Montpellier University Hospital (CSE-2024-06-072). In accordance with national legislation and institutional requirements, written informed consent to participate in this study was not required from the participants or the participants' legal guardians.

# 3. Results

## 3.1. Population

During the study period, 219 transports were carried out by the PETS of Montpellier University Hospital Centre. Among them, 140 (6.3%) transports were performed for NRD. Thirty patients were excluded for the following reasons (i) 8 were already intubated at the time of the transfer regulation centre call; (ii) 9 were not supported with CPAP; (iii) 4 were transferred after the 3rd postnatal day, (iv) 7 presented with

perinatal asphyxia or severe congenital anomalies, (v) 2 had incomplete data.

The final study population included 110 infants with a mean gestational age of 37.6 ±2.2 weeks and a mean birthweight of 3042 ±615 g. Among them, 38 (35%) were born at 34-36
weeks' GA and 11 (10 %) presented with IUGR. The perinatal characteristics of the study population are summarized in Table 1.

<table><caption>**Table 1**

Characteristics of the study population.</caption><thead><tr><th></th><th>2021-2023<br>(N = 110)</th><th>2021<br>(N =<br>38)</th><th>2022<br>(N =<br>45)</th><th>2023<br>(N =<br>27)</th></tr></thead><tbody><tr><td colspan="5"><strong>Perinatal data</strong></td></tr><tr><td>Twin pregnancy, n (%)</td><td>9 (8)</td><td>4 (11)</td><td>3 (7)</td><td>2 (7)</td></tr><tr><td>Maternal hypertension, n (%)</td><td>4 (4)</td><td>1 (3)</td><td>2 (4)</td><td>1 (4)</td></tr><tr><td>Maternal diabetes, n (%)</td><td>11 (10)</td><td>4 (11)</td><td>3 (7)</td><td>4 (15)</td></tr><tr><td>PROM, n (%)</td><td>11 (10)</td><td>3 (8)</td><td>5 (11)</td><td>3 (11)</td></tr><tr><td>Caesarean delivery, n (%)</td><td>49 (45)</td><td>19 (50)</td><td>17 (38)</td><td>13 (48)</td></tr><tr><td>Male, n (%)</td><td>70 (64)</td><td>23 (61)</td><td>29 (64)</td><td>18 (67)</td></tr><tr><td>Gestational age, weeks</td><td>37.6 ± 2.2</td><td>37.7 ±<br>2.4</td><td>37.2 ±<br>2.0</td><td>37.9 ±<br>2.1</td></tr><tr><td>34-36 weeks' GA, n (%)</td><td>38 (35)</td><td>13 (34)</td><td>18 (40)</td><td>7 (26)</td></tr><tr><td>Birthweight, g</td><td>3042 ±<br>615</td><td>2923 ±<br>628</td><td>3035 ±<br>595</td><td>3159 ±<br>655</td></tr><tr><td>IUGR, n (%)</td><td>11 (10)</td><td>6 (16)</td><td>3 (7)</td><td>2 (7)</td></tr><tr><td>Macrosomia, n (%)</td><td>3 (3)</td><td>1 (3)</td><td>2 (4)</td><td>0 (0)</td></tr><tr><td>1 min Apgar score</td><td>7.2 ± 2.9</td><td>6.7 ±<br>3.3</td><td>7.7 ±<br>2.5</td><td>7.1 ±<br>2.7</td></tr><tr><td>5 min Apgar score</td><td>8.7 ± 1.7</td><td>8.5 ±<br>1.8</td><td>8.8 ±<br>1.5</td><td>8.9 ±<br>1.6</td></tr><tr><td colspan="5"><strong>Additional data transmitted to<br>the transfer regulation centre</strong></td></tr><tr><td>Type of maternity Hospital, n (%)</td><td></td><td></td><td></td><td></td></tr><tr><td>1</td><td>55 (50)</td><td>19 (50)</td><td>29 (64)</td><td>7 (26)</td></tr><tr><td>2a</td><td>50 (46)</td><td>16 (42)</td><td>15 (33)</td><td>19 (70)</td></tr><tr><td>2b</td><td>5 (4)</td><td>3 (8)</td><td>1 (2)</td><td>1 (4)</td></tr><tr><td>FiO<sub>2</sub>, %</td><td>32.6 ±<br>16.0</td><td>33.0 ±<br>17.5</td><td>32.6 ±<br>15.7</td><td>32.2 ±<br>14.1</td></tr><tr><td>Pneumothorax, n (%)</td><td>9 (8)</td><td>3 (8)</td><td>3 (7)</td><td>3 (11)</td></tr><tr><td>Peripheral venous access, n (%)</td><td>71 (65)</td><td>30 (79)</td><td>25 (56)</td><td>16 (59)</td></tr><tr><td>Umbilical venous catheter, n (%)</td><td>7 (6)</td><td>2 (5)</td><td>5 (11)</td><td>0 (0)</td></tr><tr><td>Nasogastric tube, n (%)</td><td>51 (46)</td><td>21 (55)</td><td>17 (40)</td><td>13 (48)</td></tr><tr><td colspan="5"><strong>Intervention requiring a<br>complete team</strong></td></tr><tr><td>Intubation and surfactant and INO</td><td>3 (3)</td><td>1 (3)</td><td>0</td><td>2 (7)</td></tr><tr><td>Intubation and surfactant</td><td>1 (1)</td><td>0</td><td>1 (2)</td><td>0</td></tr><tr><td>Surfactant without intubation</td><td>1 (1)</td><td>1 (3)</td><td>0</td><td>0</td></tr><tr><td>Non-invasive INO administration</td><td>3 (3)</td><td>2 (5)</td><td>1 (2)</td><td>0</td></tr><tr><td>Needle aspiration for<br>pneumothorax</td><td>2 (2)</td><td>0</td><td>2 (4)</td><td>0</td></tr><tr><td>Prostaglandin E1 infusion and<br>umbilical venous catheter<br>placement</td><td>1 (1)</td><td>1 (1)</td><td>0</td><td>0</td></tr><tr><td>Neurological distress</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Cardio-circulatory distress</td><td>0</td><td>0</td><td>0</td><td>0</td></tr></tbody></table>

Legend: FiO₂: fraction of inspired oxygen; GA: gestational age; INO: inhaled nitric oxide; IUGR: intrauterine growth restriction; PROM: premature rupture of membranes.
Date are numbers (%) or means (± standard deviation).

## 3.2. Additional data provided to the transfer regulation centre

The mean FiO₂ of infants supported with CPAP was 32.6 ±16.0 %. The Silverman-Anderson retraction score, available in 38 (35 %) cases, was 3.7 ±1.8. Regarding invasive procedures, 71 (65 %) infants had a peripheral venous catheter, 7 (6 %) had an umbilical venous catheter, and 51 (46 %) had a nasogastric tube. Chest X-rays were performed in 62 (56 %) infants, revealing pneumothorax in 9 cases.
### 3.3.Prediction of clinical intervention from data provided to the transfer regulation centre

A complete team was mobilized in 104 (95 %) of the transports. An intervention requiring the presence of a complete team occurred in 11 (10 %) cases (Table 1). Additionally, the PETS team performed the following interventions during transport: placement of a supplementary peripheral venous catheter in 5 infants, insertion of a nasogastric tube in 3 infants, and administration of a 10 % glucose bolus in 2 infants presenting with hypoglycaemia. Bilevel non-invasive ventilation was not required in any case.

A comparison of infants' characteristics at the time of the transfer regulation centre call, based on the occurrence of an intervention requiring a complete team, is shown in Table 2. Interventions were significantly associated with higher $FiO_2$ values (71.4 ±18.5 % vs. 28.3 ±8.0 %; *P* <0.01), the presence of pneumothorax on chest X-ray (*P* <0.01), and the highest type of sending maternity (*P* <0.01).

<table><caption>**Table 2**
Characteristics of infants at the call to the transfer regulation centre, according to occurrence of an intervention requiring a complete team.</caption><thead><tr><th rowspan="2">Variables</th><th>Intervention</th><th>Intervention</th><th rowspan="2">P</th></tr><tr><th>No</th><th>yes</th></tr><tr><td></td><td>N = 99</td><td>N = 11</td><td></td></tr></thead><tbody><tr><td>Twin pregnancy, n (%)</td><td>8 (8)</td><td>1 (9)</td><td>0.99</td></tr><tr><td>Maternal hypertension, n (%)</td><td>4 (4)</td><td>0 (0)</td><td>0.99</td></tr><tr><td>Maternal diabetes, n (%)</td><td>10 (10)</td><td>1 (9)</td><td>0.99</td></tr><tr><td>PROM, n (%)</td><td>9 (9)</td><td>2 (18)</td><td>0.80</td></tr><tr><td>Caesarean delivery, n (%)</td><td>44 (44)</td><td>5 (45)</td><td>0.99</td></tr><tr><td>Male, n (%)</td><td>63 (64)</td><td>7 (64)</td><td>0.99</td></tr><tr><td>Gestational age, weeks</td><td>37.5 ± 2.2</td><td>38.3 ± 2.5</td><td>0.23</td></tr><tr><td>34-36 weeks' GA, n (%)</td><td>35 (35)</td><td>3 (27)</td><td>0.75</td></tr><tr><td>Birthweight, g</td><td>3089 ± 625</td><td>3071 ± 576</td><td>0.87</td></tr><tr><td>IUGR, n (%)</td><td>8 (8)</td><td>3 (27)</td><td>0.08</td></tr><tr><td>Macrosomia, n (%)</td><td>3 (3)</td><td>0 (0)</td><td>0.99</td></tr><tr><td>1 min Apgar score</td><td>7.4 ± 2.8</td><td>6.1 ± 3.4</td><td>0.21</td></tr><tr><td>5 min Apgar score</td><td>8.8 ± 1.7</td><td>8.2 ± 1.8</td><td>0.25</td></tr><tr><td>Type of initial maternity Hospital, n (%)</td><td></td><td></td><td>&lt;0.01</td></tr><tr><td>1</td><td>54 (55)</td><td>1 (9)</td><td></td></tr><tr><td>2a</td><td>43 (43)</td><td>7 (64)</td><td></td></tr><tr><td>2b</td><td>2 (2)</td><td>3 (27)</td><td></td></tr><tr><td>FiO<sub>2</sub>, %</td><td>28.3 ± 8.0</td><td>71.4 ± 18.5</td><td>&lt;0.01</td></tr><tr><td>Pneumothorax, n (%)</td><td>5 (9)</td><td>4 (57)</td><td>&lt;0.01</td></tr></tbody></table>

Legend: $FiO_2$: fraction of inspired oxygen; GA: gestational age; iNO: inhaled nitric oxide; IUGR: intrauterine growth restriction; PROM: premature rupture of membranes.
Date are numbers (%) or means (± standard deviation).

The area under the ROC curve for $FiO_2$ at the time of the call and the need for a complete team was 0.99 (95 % CI 0.97–1.01, *P* =0.001). A cut-off value of >40 % had a sensitivity of 91 %, specificity of 98 %, positive predictive value of 83 %, and negative predictive value of 99 %. The only false negative case involved a 35-week gestation newborn with a birthweight of 2730 g, supported with CPAP and $FiO_2$ of 40 %, who received surfactant without intubation.
## 4.Discussion

This retrospective study analysed inter-hospital transport of 110 late preterm and term infants with NRD, performed by a French Paediatric Emergency Transport Service. The results indicate that although a complete team was mobilised in 95 % of cases, only 10 % of these transfers ultimately required an intervention justifying the presence of such a team.

Clinical interventions necessitating the complete transport team are uncommon during inter-hospital transfers of late preterm and term infants with NRD. When required, they primarily consist of escalating respiratory support (e.g., intubation), initiating inhaled nitric oxide (iNO), or performing needle aspiration for pneumothorax. NRD is the leading cause of emergency transport in newborns[10]. While most reports focus on invasive ventilation [11,12], there has been a gradual increase in the use of non-invasive ventilation during neonatal transfers, particularly for late preterm and term infants[13]. This trend is mainly due to transient tachypnea of the newborn, the most common cause of NRD in these patients[14]. In this context, CPAP is the first-line respiratory support because of its wide availability, proven safety, and relative efficacy[4]. Other causes of respiratory distress, such as aspiration syndrome, surfactant deficiency, or pneumonia, present distinct features on lung radiography and ultrasound. These conditions typically require higher oxygen levels and may necessitate endotracheal intubation and/or surfactant administration. As previously reported [15], nearly half of the neonates in our cohort with pneumothorax who required retrieval had undergone a medical intervention before transfer. In contrast, the other infants had mild to moderate pneumothorax that did not require intervention prior to or during transport, nor during hospitalization. Currently, there are no guidelines to assist clinicians in managing these situations of transport with pneumothorax due to the absence of a validated risk assessment tool.

Our results highlight that the degree of oxygen dependency is a key factor in determining the appropriate emergency transport team. The $FiO_2$ threshold is both simple and clinically meaningful, and our study suggests that a cut-off value of ≥40 % is relevant for predicting the need for clinical interventions requiring the complete transport team. Indeed, patients requiring high $FiO_2$ levels are at increased risk of severe respiratory illness and/or developing PPHN [16]. In such cases, the paediatrician's role is to distinguish between cyanotic congenital heart disease and PPHN [17], especially to identify transposition of the great arteries or total anomalous pulmonary venous return. Research has shown that improving referral call handling processes can enhance dispatch and mobilisation times for neonatal transport teams[18]. Therefore, standardising data collection before, during, and after inter-hospital transfers is essential[19]. Gathering information from clinicians at the referring maternity ward facilitates the identification of potential causes of severe respiratory illness and/or secondary PPHN, such as meconium aspiration syndrome, pulmonary haemorrhage, or hyaline membrane disease [20]. Additionally, simultaneous measurement of preductal and postductal oxygen saturation and performing a chest X-ray may facilitate diagnosis[16]. Portable ultrasound imaging devices, now compatible with neonatal transport, enable cardiac anatomy and function assessments, provided that the transport team includes clinicians skilled in ultrasound[21]. Ideally, targeted echocardiography should be performed to rule out
congenital heart disease and assess PPHN severity, the impact of treatment on pulmonary pressures, right ventricular function, and the direction of atrial and ductal shunts[22]. In our study, ultrasound imaging supported the prescription of pulmonary vasodilator or ductodilator treatment in 7 of the 11 cases that required clinical intervention. Interestingly, clinical interventions occurred more frequently when the initial transfer request originated from maternity wards with higher care levels. In our cohort, type 2b centres typically requested transfers for more severe NRD cases. Among the three infants concerned, two exhibited worsening NRD despite effective CPAP at 6–7 cmH₂O and 60 % FiO₂, requiring invasive surfactant administration, while one infant, despite surfactant therapy without intubation, needed non-invasive iNO for PPHN. Effective communication with these centres should include information on prior treatments and their efficacy, as well as the duration of NRD symptoms.

Most transfers of term and near-term infants with NRD managed by CPAP did not necessitate clinical intervention, suggesting that these transports could be handled by an advanced neonatal nurse. Previous studies have demonstrated that healthcare professionals such as neonatal nurse practitioners can effectively provide expertise and leadership in neonatal resuscitation, stabilisation [23], and transfer [7]. According to the American Academy of Paediatrics, neonatal nurse practitioners work in collaboration with physicians, typically paediatricians or neonatologists, and may independently perform certain procedures[24]. In our context, advanced practice nurses — typically trained to a master's level — remain a scarce resource, and our department does not currently have such professionals. Advanced neonatal nurses recruited in our Paediatric Emergency Transport Service (PETS) have at least one year of experience in neonatal resuscitation or paediatric emergencies, specialized training in neonatal transport, and certification from the Newborn Life Support (NLS) program of the European Resuscitation Council[25]. Most of them are also NLS trainers. These nurses are proficient in essential stabilisation procedures, including CPAP setup, venous and nasogastric tube placement, vital sign monitoring, oxygen titration, and administration of prescribed treatments or protocol-based care. In other countries, notably in the United States and the United Kingdom, the organisation of neonatal transport also relies on specialised teams, sometimes including neonatal nurse practitioners for less complex cases[7,8]. Our results align with these international practices, which favour optimising human resources according to case severity. However, the implementation of advanced nursing teams remains limited in France, partly due to a lack of official recognition of this specific role and appropriate training programs.

## 4.1. Study limitations

Our study has several limitations. As with any observational, single-centre study, the findings may not be easily generalizable to other institutions. Indeed, the roles of healthcare professionals in paediatric transport teams vary from one country to another. In some countries, team composition is fixed, while in others, the skill mix is considered on a case-by-case basis[26]. The definition of clinical interventions used in our study is somewhat arbitrary, as we selected the most significant acts based on the training of healthcare professionals in our country. Transport teams often consist of personnel with different levels of seniority, including physicians, nurses, and allied health professionals with significant paediatric intensive care expertise. Notably, the presence of respiratory therapists is common in North America but remains rare in most other regions. We chose to include only infants supported by CPAP, as this modality is considered a severity criterion according to the
regional protocol for managing neonatal NRD. However, the high-flow nasal cannula (HFNC) is increasingly becoming the most commonly used non-invasive respiratory support mode during neonatal transport [27], and its effectiveness appears comparable to that of CPAP in this context[28]. Moreover, our study design did not allow us to evaluate the impact of travel time, distance, or mode of transport (ground or air) when determining whether to deploy a complete team. Moreover, the retrospective design of the study did not allow us to account for some dynamic parameters useful for decision-making, in particular the evolution of respiratory rate, $FiO_2$, duration of CPAP support, and the presence of apnoea before the call to the transfer regulation centre. Finally, we excluded infants affected by perinatal asphyxia or congenital malformations, which are not always identified when initially contacting the regulation centre.

## 5. Conclusion

The degree of oxygen dependency and the presence of a pneumothorax are key information for targeting the emergency transport team in near-term and term newborns with NRD supported with CPAP and requiring transfer. Further studies are needed to establish the safety of performing these transports by advanced neonatal nurses alone in the absence of predictive criteria for clinical intervention. Optimising team composition according to patient severity could help improve resource allocation and maintain availability for primary care interventions.

## Funding

This work was supported by the Montpellier University Hospital, France.

## Declaration of competing interest

The authors have no relevant financial or non-financial interests to disclose.

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