Nasal CPAP or intubation at birth for very preterm infants.

BACKGROUND Bronchopulmonary dysplasia is associated with ventilation and oxygen treatment. This randomized trial investigated whether nasal continuous positive airway pressure (CPAP), rather than intubation and ventilation, shortly after birth would reduce the rate of death or bronchopulmonary dysplasia in very preterm infants. METHODS We randomly assigned 610 infants who were born at 25-to-28-weeks' gestation to CPAP or intubation and ventilation at 5 minutes after birth. We assessed outcomes at 28 days of age, at 36 weeks' gestational age, and before discharge. RESULTS At 36 weeks' gestational age, 33.9% of 307 infants who were assigned to receive CPAP had died or had bronchopulmonary dysplasia, as compared with 38.9% of 303 infants who were assigned to receive intubation (odds ratio favoring CPAP, 0.80; 95% confidence interval [CI], 0.58 to 1.12; P=0.19). At 28 days, there was a lower risk of death or need for oxygen therapy in the CPAP group than in the intubation group (odds ratio, 0.63; 95% CI, 0.46 to 0.88; P=0.006). There was little difference in overall mortality. In the CPAP group, 46% of infants were intubated during the first 5 days, and the use of surfactant was halved. The incidence of pneumothorax was 9% in the CPAP group, as compared with 3% in the intubation group (P<0.001). There were no other serious adverse events. The CPAP group had fewer days of ventilation. CONCLUSIONS In infants born at 25-to-28-weeks' gestation, early nasal CPAP did not significantly reduce the rate of death or bronchopulmonary dysplasia, as compared with intubation. Even though the CPAP group had more incidences of pneumothorax, fewer infants received oxygen at 28 days, and they had fewer days of ventilation. (Australian New Zealand Clinical Trials Registry number, 12606000258550.).

[1]  H. Aly.  Is It Safer to Intubate Premature Infants in the Delivery Room?: In Reply , 2006, Pediatrics.

[2]  Peter G Davis,et al.  Endotracheal Intubation Attempts During Neonatal Resuscitation: Success Rates, Duration, and Adverse Effects , 2006, Pediatrics.

[3]  R. Polin,et al.  Variables associated with the early failure of nasal CPAP in very low birth weight infants. , 2005, The Journal of pediatrics.

[4]  M. Walsh,et al.  Validation of the National Institutes of Health Consensus Definition of Bronchopulmonary Dysplasia , 2005, Pediatrics.

[5]  S. Kazzi,et al.  Oxygen Delivery Through Nasal Cannulae to Preterm Infants: Can Practice Be Improved? , 2005, Pediatrics.

[6]  N. Finer,et al.  Neonatal intubation: success of pediatric trainees. , 2005, The Journal of pediatrics.

[7]  S. Shankaran,et al.  Adverse Neurodevelopmental Outcomes Among Extremely Low Birth Weight Infants With a Normal Head Ultrasound: Prevalence and Antecedents , 2005, Pediatrics.

[8]  P. Davis,et al.  Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants. , 2005, The Cochrane database of systematic reviews.

[9]  W. Poole,et al.  Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial , 2004, Pediatrics.

[10]  B. Morris,et al.  Early surfactant for neonates with mild to moderate respiratory distress syndrome: a multicenter, randomized trial. , 2004, The Journal of pediatrics.

[11]  Kelly L. Lundstrom.  Early nasal continuous positive airway pressure for preterm neonates: the need for randomized trials , 2003, Acta paediatrica.

[12]  G. Kelly.  Disorders of transition , 2003 .

[13]  M. Dunn,et al.  Approaches to the initial respiratory management of preterm neonates. , 2003, Paediatric respiratory reviews.

[14]  M. Thomson,et al.  Continuous Positive Airway Pressure and Surfactant; Combined Data from Animal Experiments and Clinical Trials , 2004, Neonatology.

[15]  L. Doyle,et al.  Evaluating "old" definitions for the "new" bronchopulmonary dysplasia. , 2002, The Journal of pediatrics.

[16]  L. Storme,et al.  Effects of nasal continuous positive airway pressure (NCPAP) on breathing pattern in spontaneously breathing premature newborn infants , 2001, Intensive Care Medicine.

[17]  A. D. Klerk,et al.  Nasal continuous positive airway pressure and outcomes of preterm infants. , 2001 .

[18]  AM De Klerk,et al.  Nasal continuous positive airway pressure and outcomes of preterm infants , 2001, Journal of paediatrics and child health.

[19]  M. Moore,et al.  Antenatal glucocorticoid treatment does not reduce chronic lung disease among surviving preterm infants. , 2001, The Journal of pediatrics.

[20]  C R Bauer,et al.  Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. , 2001, Pediatrics.

[21]  E. Bancalari,et al.  Bronchopulmonary dysplasia. , 1986, Pediatric clinics of North America.

[22]  A. Moessinger,et al.  [Early application of CPAP in newborns with gestational age below 34 weeks lowers intubation rate and shortens oxygen therapy without altering mortality and morbidity]. , 2000, Schweizerische medizinische Wochenschrift.

[23]  R. Soll,et al.  Prophylactic synthetic surfactant for preventing morbidity and mortality in preterm infants. , 1998, The Cochrane database of systematic reviews.

[24]  R. Soll,et al.  Prophylactic natural surfactant extract for preventing morbidity and mortality in preterm infants. , 2000, The Cochrane database of systematic reviews.

[25]  P. Davis,et al.  Continuous distending pressure for respiratory distress syndrome in preterm infants. , 2000, The Cochrane database of systematic reviews.

[26]  H. Hummler,et al.  Delivery Room Management of Extremely Low Birth Weight Infants: Spontaneous Breathing or Intubation? , 1999, Pediatrics.

[27]  G. Greisen,et al.  Nasal continuous positive airway pressure and early surfactant therapy for respiratory distress syndrome in newborns of less than 30 weeks' gestation. , 1999, Pediatrics.

[28]  U. Thome,et al.  The effect of positive endexpiratory pressure, peak inspiratory pressure, and inspiratory time on functional residual capacity in mechanically ventilated preterm infants , 1998, European Journal of Pediatrics.

[29]  J. Tyson,et al.  Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. , 1998, American journal of obstetrics and gynecology.

[30]  E. Özek,et al.  Prophylactic animal derived surfactant extract for preventing morbidity and mortality in preterm infants , 1997 .

[31]  C. Fusch,et al.  Early nasal continuous positive airway pressure treatment reduces the need for intubation in very low birth weight infants , 1997, European Journal of Pediatrics.

[32]  H. Lagercrantz,et al.  Neonatal care of very‐low‐birthweight infants in special‐care units and neonatal intensive‐care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses , 1997, Acta paediatrica (Oslo, Norway : 1992). Supplement.

[33]  V. Millet,et al.  Pression positive continue précoce en salle de travail , 1997 .

[34]  J. Bartoli,et al.  [Early continuous positive pressure in the labor room]. , 1997, Archives de pediatrie : organe officiel de la Societe francaise de pediatrie.

[35]  C. Poets,et al.  Changes in intubation rates and outcome of very low birth weight infants: a population-based study. , 1996, Pediatrics.

[36]  T. Jacobsen,et al.  “Minitouch” treatment of very low‐birth‐weight infants , 1993, Acta paediatrica.

[37]  Kame E. Lundstrom,et al.  Early treatment with nasal‐CPAP , 1993, Acta paediatrica.

[38]  S. Lindequist,et al.  Early treatment with nasal continuous positive airway pressure in very low‐birth‐weight infants , 1993, Acta paediatrica.

[39]  Hl Hulliduy.  Continuous positive airway pressure , 1993 .

[40]  H. Halliday.  Continuous positive airway pressure. , 1993, Acta paediatrica.

[41]  J D Horbar,et al.  Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Network. , 1991, Pediatrics.

[42]  C. Ringsted,et al.  Early Treatment of Idiopathic Respiratory Distress Syndrome Using Binasal Continuous Positive Airway Pressure , 1990, Acta paediatrica Scandinavica.

[43]  I. Chalmers,et al.  The effects of corticosteroid administration before preterm delivery: an overview of the evidence from controlled trials , 1990, British journal of obstetrics and gynaecology.

[44]  Desmond K. Runyan,et al.  Risk factors for chronic lung disease in infants with birth weights of 751 to 1000 grams. , 1989, The Journal of pediatrics.

[45]  A. Ohlsson,et al.  Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. , 1988, Pediatrics.

[46]  S. Hurd,et al.  Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. , 1987, Pediatrics.

[47]  E. Shinebourne,et al.  Continuous positive airway pressure , 1974, Anaesthesia.

[48]  J. Kitterman,et al.  Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. , 1971, The New England journal of medicine.