NEW YORK (Reuters Health) – The early use of nasal continuous positive airway pressure (nCPAP) reduces the number of preterm babies who are intubated and given surfactant.
In a prospective randomized study of more than 600 very preterm infants, those who were initially managed with nCPAP or intubation, surfactant and rapid extubation to nCPAP fared similarly to those treated with prophylactic surfactant followed by a period of mechanical intubation.
“This does fly in the face of what many clinicians, especially in the US, had believed to be optimal management for this group of babies – elective intubation, surfactant and ventilation,” Dr. Michael Dunn, from the department of newborn and developmental pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada, told Reuters Health.
“It looks like clinicians managing early preemies should attempt to provide primary respiratory support with CPAP followed by selective surfactant treatment if indicated,” Dr. Dunn said.
“The best threshold for surfactant treatment has not been clearly established, but it appears that babies started out on CPAP do at least as well as those electively intubated and the less invasive approach has its appeal,” he added.
His study appears in the November issue of Pediatrics, available online now.
Most neonates born at less than 30 weeks’ gestation need respiratory support after birth. Dr. Dunn’s team compared the effect of three distinct approaches to the initial respiratory management of 648 very preterm infants born between 26 and 30 weeks gestation.
Before delivery, the infants were randomly assigned to prophylactic surfactant (PS); prophylactic surfactant with rapid extubation to bubble nCPAP (intubate-surfactant-extubate; ISX); or initial management with bubble nCPAP and selective surfactant therapy (nCPAP).
According to the investigators, there were no statistically significant between-group differences in the combined primary outcome of bronchopulmonary dysplasia (BPD) or death at 36 weeks’ postmenstrual age.
The relative risk of BPD or death was 0.78 for the ISX group and 0.83 for the nCPAP group compared with the PS group.
In the end, 48% of infants in the nCPAP group were managed without intubation and 54% were managed without surfactant treatment.
The results of this study, Dr. Dunn said, “reinforce” the findings from two other large randomized controlled trials that examined initial respiratory management of very preterm infants; the COIN (Continuous Positive Airway Pressure or Intubation at Birth (COIN) trial and the SUPPORT (Surfactant, Positive Pressure, and Oxygenation Trial).
While the entry criteria and indications for intubation and surfactant administration in these three trials were different and no single trial was able to demonstrate a statistically significant difference, “each study showed a lower relative risk of death or BPD when infants were managed initially with nCPAP,” Dr. Dunn and colleagues note in their paper.
In theory, they say the approach of ISX approach (intubation, surfactant, and rapid extubation to nCPAP) “might be the best approach” because it allows the established benefit of prophylactic surfactant and avoids exposing infants to ventilator induced lung injury.
Reference:
Pediatrics 2011;128:e1069-e1076.
