The concept of regionalization of perinatal care has been accepted in the scientific community for many years now. The application of this concept has made it possible to greatly improve the care of the newborns at birth, as one of the main requirements of the organization of perinatal care is the fact that every newborn has the right to be born in a hospital suited to their clinical characteristics. This obviously involves birth in a Level 3 hospital for all newborns at risk of complications. This is particularly applicable to twin newborns, especially if they are premature.

In the beginning…

Our neonatal transport service in Italy began in 1995, when the regionalization of perinatal care was still in its infancy (pun intended!). At that time, it was fairly common to receive a transfer request for twin babies. In all honesty, we had some practical difficulties when introducing the service. We couldn’t load two incubators into the same ambulance, and we couldn’t handle two ambulances at the same time due to the lack of clinical staff. The only possibility, therefore, was for us to carry out two transports in quick succession, even if it was patently obvious that this was far from an ideal solution. Questions abound in such a situation, the primary one being: What could have been the criterion for choosing which twin to transfer and which twin to leave behind for the next trip? Frankly, there was no right answer. We therefore had to invent something, using our imagination. In short, we had to take an Italian approach to the problem!

Innovative solutions

We took a block of Teflon and with the help of a good mechanic, we drilled it into a ‘T’ shape; we calculated the perfect diameter of the holes with the caliper to make them compatible with the two endotracheal tubes and with the ventilator tube connector. At this point, most of the mechanical work was done – we had a ventilator, two twin newborns, an incubator and an ambulance. So, we started doing twin transports. In 2013, when we had transported 92 newborns, i.e. 46 pairs of twins, we collected and published our data (Air Medical Journal 2013;32(6):334–337).

Much praise, but also criticism, followed. The most biting ones were reported in a double interview between Dr Bronson (USA), against; Dr Teasdale (UK), in favor; and me (Consultant 360, Reuters; www.consultant360.com/story/can-newborn-twins-be-transported-single-ven…).

Re-breathing concerns

The critical point raised by those criticizing the approach was the possibility of re-breathing between one twin and the other. In addition, questions were raised about our assumption that, as twins, the two newborns most likely had an equivalent respiratory condition. We took these criticisms into consideration, even though our data denied that these supposed negative events actually played a role in the outcomes. Of particular note is that, for all 92 newborns upon entry into intensive care, and therefore at the end of transport, blood CO₂ values were within normal limits.

Double ventilators

Due to the concerns raised by our esteemed colleagues and peers, we started thinking about how to change our approach. Since it remained impossible to load two incubators on the same ambulance, we thought of mounting two ventilators on the same incubator. Columbus’ egg, I would say! In practice, the ‘T’ bifurcation was moved immediately after the cylinder, thus allowing a single cylinder to power two ventilators.

Having two ventilators available means it is possible to transport two very different newborns, not just twins

This new method of transporting twins immediately brought about a notable series of advantages. There was no longer the risk of re-breathing; different ventilation modes could be used between the two twins: for example, one treated with continuous positive airway pressure (CPAP) and the other with mechanical ventilation. The fact that it was no longer necessary to find a ventilation mode of compromise, so to speak, by treating the two newborns with a single choice of ventilatory assistance, not only enabled us to choose a method in a more targeted way according to the needs of the individual newborns, but also freed us from the bondage of the twins. By this I mean that having two ventilators available means it is possible to transport two very different newborns, not just twins, but, for example, a premature baby with respiratory distress syndrome (RDS) and a near-term newborn with a wet lung. Each, obviously, with very specific ventilation settings required. I would therefore say a decisive step forward. With this second way of approaching the problem, i.e. the use of two ventilators, when we reached 44 newborns (22 pairs of twins), we decided to again analyze our experience and compare it with the previous one (Air Medical Journal 2023;42(4):246–251).

Conclusion is clear

The fact that we transported fewer newborns lies in the fact that, fortunately, the healthcare system regionalization process improved from year to year, resulting in an ever greater number of twins, especially premature ones, being born in a Level 3 hospital, namely the Gaslini of Genoa, Italy, home of our intensive care unit and base of our transport service. The comparison between our two studies gave very positive results. We have been able to conclude that, although transporting twins with respiratory distress syndrome remains challenging, 27 years of experience have convinced us that transporting twins with a single ventilator is possible. Nevertheless, in our opinion, using two ventilators mounted on the same transport module is a much better choice in terms of both clinical performance and logistics, while the cost could be a weak point.

Cost concerns

Here, in fact, are the costs and the logistics. These are very delicate aspects for which further investigation is necessary. Today, a good transport incubator can cost between €80,000 and €100,000. By ‘good’ incubator, I mean equipped with a modern ventilator, updated monitoring systems, infusion pumps and not much more. But if we focus on the ventilators available on the market today, we find many opportunities with very different performances and costs.

Obviously we cannot forget that to carry two twins at the same time we also need double effective monitoring as well as adequate support for infusion therapy. If we think about setting up a transport incubator permanently for this purpose, we will have to deal with costs, weight, difficulty in setting up and the need for ease of use. If, on the contrary, we consider having an incubator set up if necessary for the transport of twins, this will still have to be designed in advance for rapid set-up. In this second case, therefore, there would be no savings for the purchase of the necessary equipment, but an overall weight that can vary depending on the circumstances.

This second option can be useful for twin transportation requests. But, if the transport service found itself in need of an unexpected double transport, not of twins, but of two unrelated newborns, finding itself with an incubator that was not properly set up would prevent an effective response in this second case. Obviously every decision is up to each individual transport service, to be adapted according to its needs.

Equipment performance

The old and traditional pneumatic ventilators are still the cheapest today. These might be limited in performance, but are reliable and easy to use. There are no electronics to go wrong; in short, all old-school stuff. The weak point is that this type of ventilator needs to be powered by both oxygen and medical air cylinders. Considering that powering two ventilators simultaneously involves a high consumption of gas to maintain high delivery flows, the need for cylinders of at least five liters of capacity each (and for long flights they may not be sufficient) becomes a priority, resulting in a high weight of the incubator set-up.

The most modern turbine ventilators do not need to be powered by medical air cylinders; this has the advantage that the air tank can be replaced with a second oxygen tank, doubling the autonomy

The most modern turbine ventilators do not need to be powered by medical air cylinders; this has the advantage that the air tank can be replaced with a second oxygen tank, doubling the autonomy. These ventilators are much more expensive than older pneumatic ones, but offer many more ventilation options available as an advantage. You can also opt for a mixed solution. A turbine ventilator coupled with a pneumatic one (when we adopted this solution we had good feedback) can be an option: reduced expense, but the need for the medical air cylinder remains.

Personally I have no experience with the use of ventilators capable of offering high frequency ventilation, although I think that for reasons of cost, weight, size and considerable logistical difficulties, they cannot be the solution for the simultaneous transport of twins.

Two for one?

There is also a further issue to consider: it is not expressly forbidden to transport two newborns within a single incubator; however, nor is it expressly allowed. The transport incubators currently available on the market are generally approved for between 4kg and 6kg in weight, depending on the model. Twins at birth, together, rarely weigh more than 6kg. To resolve this delicate issue, we personally wrote very detailed internal recommendations, accepted by the management of our hospital. In them, we have declared that, in the event of a request for the transfer of newborns, to guarantee them the best and fastest assistance, our service, as it is perfectly equipped for this need, opts for the simultaneous transfer of both infants, placing both newborns together in the same incubator.

To date, there have been no complaints. Obviously this could be a good solution or an unacceptable solution, depending on the individual hospital managements or any local laws of which I am unaware.