Retinopathy of prematurity is a disease of the developing retina driven largely by abnormal vascular growth after premature birth, and its global burden has been rising as survival of extremely preterm infants improves. Anti-vascular endothelial growth factor agents such as ranibizumab have become an increasingly important treatment option, offering a faster alternative to laser photocoagulation in many cases. The RAINBOW randomized trial and its five-year follow-up demonstrated that ranibizumab could match laser therapy in very low birthweight infants, and network meta-analyses comparing aflibercept, bevacizumab, conbercept and ranibizumab have reinforced the role of intravitreal injections in modern practice. Yet the injection itself is a surgical procedure: it requires general anesthesia in an infant who may weigh barely a kilogram, whose respiratory drive is unstable, and whose airway anatomy makes standard adult techniques hazardous.

The vulnerability of preterm infants under anesthesia is well documented. Their chest walls are compliant, their diaphragms fatigue easily, and their brains exert immature control over breathing patterns. Apnea, bradycardia and desaturation are recognized hazards of general anesthesia in this population, and the risk of postoperative respiratory failure is a central concern in any procedure requiring sedation. Previous work has shown that prematurity is a critical risk factor for respiratory failure after even brief operations such as inguinal hernia repair, and international registries of neonatal intubation reveal that a substantial fraction of attempts are associated with adverse events, particularly when multiple attempts are needed. Against this backdrop, the choice between a supraglottic device that sits above the vocal cords and an endotracheal tube that passes through them carries real physiological weight.

The Beijing team examined 134 preterm infants who received intravitreal ranibizumab under general anesthesia in the operating room. Of these, 83 were managed with a laryngeal mask airway, a device that seals over the laryngeal inlet without entering the trachea, while 51 underwent endotracheal intubation. The primary outcome was escalation of respiratory support within 24 hours after the procedure, a clinically meaningful measure of how hard the infant’s respiratory system had to work to recover. Because this was not a randomized trial, the researchers recognized that infants receiving each airway device might differ systematically in weight, gestational age, baseline oxygen needs and comorbidities. To address this, they applied inverse probability of treatment weighting, a statistical technique that reweights the two groups so that measured baseline characteristics are balanced, mimicking some of the advantages of randomization.

The results were striking. Respiratory support escalation occurred in only 6 of 83 infants, or 7.2 percent, in the laryngeal mask group, compared with 20 of 51 infants, or 39.2 percent, in the intubated group. After weighting, the use of a laryngeal mask airway was associated with roughly a 64 percent lower risk of escalation relative to endotracheal intubation, with a risk ratio of 0.36 and a 95 percent confidence interval of 0.15 to 0.88, a difference that remained statistically significant at a P value of 0.026. In secondary unadjusted analyses, the pattern held: 90.4 percent of laryngeal mask infants had returned to their baseline level of respiratory support by 24 hours, versus 66.7 percent of intubated infants, and unplanned reintubation was needed in 1.2 percent of the laryngeal mask group compared with 9.8 percent of the intubated group.

The mechanisms behind these differences are plausible from first principles. Endotracheal intubation in a preterm infant is technically demanding; the narrow, floppy airway offers little margin for error, and each laryngoscopy can provoke reflex bradycardia, desaturation and airway trauma. The tube itself bypasses the larynx, eliminating the warming, humidification and filtration the upper airway normally provides, and it can trigger bronchial irritation and laryngeal edema that persist after extubation. Extubation is its own stress test, requiring the infant to coordinate breathing through a newly irritated airway. A laryngeal mask airway, by contrast, avoids direct tracheal instrumentation, can often be inserted with less stimulation, and is removed with less disturbance, allowing a smoother transition back to the infant’s preoperative respiratory regimen, whether that was room air, nasal cannula or noninvasive support.

The study extends earlier observations in an important direction. A 2025 analysis published in the same journal found that airway management might influence postoperative ventilation needs in preterm infants after laser treatment for retinopathy of prematurity, a longer and more painful procedure. The Beijing team deliberately focused on the briefer setting of intravitreal injection, where the anesthetic exposure is shorter and the argument for minimizing airway instrumentation is arguably stronger. Their use of inverse probability of treatment weighting also places the work among a growing family of studies, including randomized trials comparing supraglottic devices with endotracheal tubes in former preterm infants and retrospective comparisons in hernia surgery, that collectively point toward gentler airway strategies for this population. European Society of Anaesthesiology and Intensive Care guidelines on neonatal and infant airway management provide a framework for individualized device selection, and this study offers data specifically relevant to the ophthalmic operating room.

The authors are careful about the limits of their evidence. This was a single-center retrospective cohort, and the findings are associative and hypothesis-generating rather than proof of causation. Clinicians chose the airway device, and although weighting balanced the measured characteristics, unmeasured factors, such as the severity of underlying lung disease or the anesthesiologist’s judgment about airway difficulty, could still have influenced both device selection and outcomes. The conclusions apply only when laryngeal mask placement is technically feasible and clinically appropriate; infants with difficult airways, high oxygen requirements or other contraindications may still benefit from a secured endotracheal tube. The researchers call for prospective multicenter studies to confirm the association and to define which infants stand to gain the most from a supraglottic approach.

Even so, the practical implications are immediate and compelling. For neonatologists and anesthesiologists planning an intravitreal injection, the study suggests that the airway decision should be treated as a modifiable risk factor rather than a routine default. Every avoided intubation spares a fragile infant the trauma of laryngoscopy, the irritation of a tracheal tube and the physiologic cost of extubation, and the data indicate that this sparing translates into measurably faster recovery of baseline respiratory support. As anti-VEGF injections become an ever more common treatment for retinopathy of prematurity worldwide, the number of preterm infants passing through operating rooms for this brief procedure will continue to grow. If larger prospective trials confirm what this Beijing cohort observed, a simple change in airway practice could quietly prevent a meaningful share of postoperative respiratory complications in some of medicine’s most vulnerable patients, turning a routine anesthetic choice into a genuine intervention for lung protection.

Subject of Research: Airway management strategies and postoperative respiratory outcomes in preterm infants receiving intravitreal injection for retinopathy of prematurity

Article Title: Airway management and postoperative respiratory recovery after intravitreal injection in preterm infants

Article References: CHEN, Y., CHENG, Y., YAN, F., PAN, S., & HAN, D. (2026). Airway management and postoperative respiratory recovery after intravitreal injection in preterm infants. Pediatric Research. https://doi.org/10.1038/s41390-026-05512-4

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05512-4

Keywords: retinopathy of prematurity, preterm infants, laryngeal mask airway, endotracheal intubation, intravitreal injection, ranibizumab, general anesthesia, respiratory support, neonatal airway management, inverse probability weighting, Pediatric Research, postoperative recovery