cpap and rds: are we finally on the road to enlightenment?

CPAP and RDS: Are We Finally on the Road to Enlightenment?

Morgan Stanley Children’s Hospital

Columbia University

Richard A. Polin M.D.

Milestones in Neonatal Intensive Care

� Epidemiology of bronchopulmonary dysplasia (BPD) and

strategies for prevention.

� Rationale for use of CPAP as an initial mode of respiratory

support in neonates with respiratory distress

� Predicting CPAP failure

� Value and limitations of the INSURE Approach

� Benefits of Bubble CPAP as a preferred method to deliver

positive airway pressure

Outline

T I have no financial relationships to disclose or conflicts of interest to

resolve.

T I will not discuss any unapproved, investigational or off-label use of

drugs

Disclosures

T A 0.75 kg infant is born following a 27 week gestation. The infant exhibits

immediate signs of respiratory distress and is administered 30% O2 in the

delivery room. He is given ampicillin and gentamicin and transported to the

NICU. A chest x-ray demonstrates a ground glass appearance with air

bronchograms. What should be done now?

Case

A. Intubate and administer surfactant; wean ventilation as tolerated

B. Intubate, administer surfactant and rapidly extubate to NPCPAP (INSURE).

C. Withhold surfactant. Place the infant IMV-NPCPAP.

D. Withhold surfactant. Place on the infant on NPCPAP and observe.

Modified from Thomas W &

Speer CP Neonatology 2011

Modified from Thomas W &

Speer CP Neonatology 2011

Erythromycin

Superoxide

dismutase

Vitamin A

Permissive

hypoxemia

Postnatal

Steroids

iNO &

CPAP

CaffeinePermissive

hypercapniaDiuretics

Fluid/colloid restriction

Antenatal steroids

Surfactant

Gentle

resuscitation

Lung Injury in the Neonate: Fundamental Concept

S If you don’t ventilate an infant, it’s hard to cause BPD!

Change in Oxygenation with Intubation

PaO2 Values

Before Intubated Intubated Extubated

91± 91 61 ± 58* 93 ± 92

1.8 ± 0.4 Kg

*P < 0.001

Harrison et al. Pediatrics 41: 549, 1968

Gregory et al. N Engl J Med 284: 1333, 1971

Treatment of idiopathic respiratory distress syndrome with

continuous positive airway pressure

Weight N PaO2 (pre) PaO2 (post)

930-1500 10 37.1 116.4

1501-2000 5 38.1 114.8

2001-3830 5 48.6 96.0

Treatment of idiopathic respiratory distress syndrome with

continuous positive airway pressure

Gregory et al. N Engl J Med 284: 1333, 1971

CPAP is Controversial

Practical skepticism “ the position that new information may be

worthy of confidence, but that acceptance depends on the

strength of the supportive data.

Skepticism and CPAP

*Kamper et al Acta Paediatr. 1992

The fundamental concept of the Kamper* study that the

“softly-softly” approach will decrease morbidity is

fundamentally flawed. Putting seriously ill babies on CPAP

alone gives the clinician much less control of cardio-

respiratory function at a time when the baby is at major risk

of sudden deterioration”

NRC Robertson Cambridge UK 1993

Acute RDS Weaning

IPPV 73% N/A

HFO 2% N/A

IMV N/A 13%

A/C 4% 15%

SIMV 13% 73%

VG 5% 6%

CPAP 2% N/A

Respiratory Support Strategies U.K.

Sharma A & Greenough. Acta Paediatrica 96: 1115-1117, 2007

Surfactant: Systematic Reviews-Mortality

RR 95%CI NNT 95% CI

Natural surfactant 0.86 0.76-0.98 50 20-1000

Multiple doses 0.63 0.39-1.02 14 7-1000

Prophylaxis 0.61 0.48-0.77 20 14-50

Early 0.87 0.77-0.99 33 17-1000

HL Halliday Journal of Perinatology 28: s47, 2008

Critique of the Surfactant Trials

T Low rates of exposure to antenatal steroids

T Infants randomized to selective treatment arms of these

trials were routinely ventilated rather than receiving CPAP

“Simplicity is the Ultimate

sophistication”

KISS: Keep it simple stupid!

T Is the use of CPAP as an initial treatment for preterm

infants with RDS evidence-based?

Yes

2.0

1.8

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0.0

BPD CPAP VLBW VENT

Pe

rce

nta

ge

of

ho

sp

ita

liza

tio

ns

wit

h d

iag

no

sis

‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06

Year

Stroustrup, A. et al. Pediatrics 2010;126:291-297

Annual Percentage Change in the Incidence of BPD

N = 9,542,032

Do clinical markers of barotrauma and oxygen toxicity explain

interhospital variation in rates of chronic lung disease?

Van Marter et al Pediatrics: 105, 1194, 2000

Babies Boston

BPD 4% 22%*

CPAP 63% 11%*

Ventilation 29% 75%*

Pulmonary Morbidity According to Gestational Age for VLBW Infants

Stoll B et al Pediatrics 126: 443, 2010

Characteristic 22 wk 23 wk 24 wk 25 wk 26 wk 27 wk 28 wk Total

Severe BPD 56% 39% 37% 26% 17% 13% 8% 18%

Surfactant 97% 97% 95% 90% 86% 78% 65% 82%

Ventilation 96% 94% 89% 76% 61% 49% 40% 62%

CPAP 0% 3% 8% 18% 30% 36% 38% 26%

N = 8575 VLBW infants (2003-2007)

Columbia Experience

• 4 year retrospective analysis (2008-11)

• 297 consecutive inborn infants BW ≤ 1000 gm

Respiratory Outcomes with CPAP 2008-2011

CPAP success@ CPAP failure Ventilated

Started

(n = 151) (n = 84) (n =62)

Weeks 26.9 ± 1.8* 25.6 ± 1.3* 24.8 ± 1.5*

Weight (g) 792.7 ± 136.1 723.1 ± 152.0 658.6 ± 141.2

*P < .001 CPAP success vs. CPAP failure & ventilated vs. CPAP failure@ CPAP success rate 64%

Respiratory Outcomes with CPAP 2008-2011

CPAP success CPAP failure Ventilated Started

(n = 151) (n = 84) (n =62)

Oxygen at 28 days 31.8% 73.8% 72.9%

Oxygen at 36 weeks 3.6% 15.4% 13.5%

Severe BPD (NICHD) 23.9% 50.7% 54.0%

Pneumothorax 3.2% 13.4% 8.1%

Mortality 8.6% 22.6% 40.3%

Death or O2 (36 wks) 11.9% 34.5% 48.4%

Death or Severe BPD 30.5% 61.9% 72.6%

80

Comparisons of respiratory outcomes between CPAP failure

and success group

02 at 28 days

CPAP failure

CPAP success

*70

60

50

40

30

20

10

0

%

02 at 36 wksPMA (VON)

*

*

*

*

BPD severe(NICHD)

02 at 36 wksPMA (VON) +

Death

BPD severe(NICHD) +

Death

Time course of CPAP failure in first 72 hr life

Infants ≤1000g with RDS requiring intubation after a trial of CPAP

Blood gases at time of failureTime of intubation pH PaCO2 PaO2

CPAP/Vent 18.35±14 hrs 7.15±.10 69±19 57±22

• Baby A.F.

• 26-week GA male with severe IUGR (500g)

• Apgar 8/9

• Initially placed on CPAP with an FiO2 30%

• Initial ABG: pH=7.35; pCO2=47; pO2=46; BE=-4

A Case of CPAP Failure

Course of CPAP failure for baby F

pH

pH

pCO2

pH

pCO2

Time of intubation

Time criteria for intubation met

Time

pC

O2

12:00 6:00 12:00 6:00 12:00 6:00 12:00 6:00 12:00 6:00

Nov 9 2012 Nov 10 2012 Nov 11 2012

30

40

50

60

70

80

90

100

6.8

6.9

7.0

7.1

7.2

7.3

7.4

7.5

At Time of Intubation:

• Time baby met consensus criteria for intubation: 23 hr

age.

• Time intubated: 32 hr age.

• ABG: pH=6.76; pCO2 > 100; pO2=15; BE=-15;

Lactate=4.7

• Curosurf given after intubation

• Slow recovery on mechanical ventilation

Why Do infants Fail CPAP?

0

ENCPAP implementation and failure rates at different gestational ages.

100

75

50

25

20 25 30 35 40

Gestational Age (wks)

Per

cen

t o

f In

fan

ts

% of infants beginning ENCPAP (squares)

% of infants failing the ENCPAP trial (triangles)

Aly H et al Pediatrics 115: 1660, 2005

7.5Total Lung Sat PC80

Success Fail Success Fail

BALF Sat PC

Large Aggregate% Secreted

60

40

20

0

10

8

6

4

2

0

5.0

2.5

0.0

75

50

25

0

% %

(µm

ol/k

g)

(µm

ol/k

g)

A

C D

B

Surfactant pools were lower in lambs that failed BCPAP

Mulrooney et al. Am. J Respir. Crit. Care Med. 171: 488, 2005

1.6.1 Studies without routine application of CDP

Bevilacqua 1996 28 136 46 132 16.9% 0.59 [0.39, 0.89]

Bevilacqua 1997 9 49 9 44 3.4% 0.90 [0.39, 2.06]

Dunn 1991 9 62 8 60 3.0% 1.09 [0.45, 2.63]

Egberts 1993 8 75 14 72 5.2% 0.55 [0.24, 1.23]

Kattwinkel 1993 3 627 11 621 4.0% 0.27 [0.08, 0.96]

Kendig 1991 23 235 40 244 14.2% 0.60 [0.37, 0.97]

Merritt 1991 27 76 21 72 7.8% 1.22 [0.76, 1.95]

Walti 1995 15 134 23 122 8.7% 0.59 [0.33, 1.08]

Subtotal (95% Cl) 1394 1367 63.3% 0.69 [0.56, 0.85]

Total events 122 172

Study or Prophylactic Selective Risk Ratio

Subgroup Events Total Events Total Weight M-H, Fixed,95% Cl

Risk Ratio

M-H, Fixed,95% Cl

1.1.2 Studies with routine application of CDP

Support 2010 114 653 94 663 33.8% 1.23 [0.96, 1.58]

Von 2010 10 209 8 221 2.8% 1.32 [0.53, 3.28]

Subtotal (95% Cl) 862 884 36.7% 1.24 [0.97, 1.58]


Total (95% Cl) 2256 2251 100.0% 0.89 [0.76, 1.04]


.2 .5 2 5

Favors prophylactic Favors selective

1

Prophylactic Surfactant vs. Selective Treatment of RDS

Neonatal Mortality

Rojas & Soll 2010 unpublished

1. Studies without routine application of CPAP

Dunn 1991 16/62 12/60 3.1% 1.29 [0.67, 2.49]

Subtotal (95% Cl) 62 60 3.1% 1.29 [0.67, 2.49]Total events 16 (Prophylactic), 12 (Selective)

2. Studies with routine application of CPAP

Dunn 2011 76/208 67/220 16.4% 1.29 [0.92, 1.57]

Support 2010 353/653 323/663 80.6% 1.11 [1.00, 1.23]

Subtotal (95% Cl) 861 883 96.9% 1.12 [1.02, 1.24]Total events 429 (Prophylactic), 390 (Selective)

Total (95% Cl) 923 943 100.0% 1.13 [1.02, 1.25]Total events 445 (Prophylactic), 402 (Selective)

0.5 0.7 1 1.5 2

Favorsexperiments

Favorscontrol

Study or subgroupProphylactic

n/NSelective

n/N

Risk RatioM-H, Fixed,

95% Cl Weight

Risk RatioM-H, Fixed,

95% Cl

Prophylactic surfactant vs. treatment of established respiratorydistress in preterm infants, Chronic lung disease or death

Intubation >> Surfactant >> Extubation

INSURE

Cochrane Database Analysis of the Need for Mechanical

Ventilation ≥ 1 hr & Air-leak Using the INSURE Approach.

RR CI

FiO2 < 0.45 0.72 (0.58-0.87)

FiO2 ≥ 0.45 0.55 (0.40-0.77)

Total 0.67 (0.57-0.79)

Stevens Cochrane Database 2007

Mechanical Ventilation Air-Leak

RR CI

FiO2 < 0.45 0.46 (0.23-0.93)

FiO2 ≥ 0.45 0.80 (0.22-2.89)

Total 0.52 (0.26-0.96)

Decreased need for O2 (RR 0.51 (0.26. 0.99) at 28 weeks, but not 36 weeks

Can We Predict CPAP Failure?

0%

10%

20%

30%

40%

50%

60%

70%

80%

GA <26 wks BW <800gm

PPV in DR A-a DO2>180

Severe RDSon CXR

CPAP success

CPAP failure

P <0.0001 for all variables

Perinatal variables: NCPAP success vs. failure

*

*

*

**

Ammari A et al J Pediatr. 147: 341, 2005

Study Population

• All inborn were categorized into 3 respiratory groups (V-F-S)

based on respiratory care modality used during first 72 hrs

• Ventilator started (V)

• Bubble CPAP started (F+S):

– CPAP failure < 72 hrs (F)

– CPAP success ≥ 72 hrs (S)

Vent. StartedN=62(21%)

CPAP StartedN=235(79%)

CPAP failN=84(36%)

72 hrs

ELBW< 1000gN= 303

Comfort

care

N=6

Alive

37

(60%)

Deaths

25

(40%)

Deaths

19 (23%)

Alive

65

(77%)

CPAP successN=151(64%)

Deaths

13 (9%)

Alive

138

(91%)

Mother Hispanic

Hypertension

Maternal diabetes

Antenatal steroids

Magnesium

GBS pos

GBS unknown

PPROM>18 hrs

Clinical chorioamnionitis

Maternal fever

Intrapartum Antibiotics

Fetal distress

Multiple birth

Vaginal delivery

SGA <10th %tile

BWT<750 g

Male

Apgar <5 (1min)

Apgar <5 (5min)

Severe RDS (CXR)

GA (wks)

BWT (g)

Initial fiO2 (%)

1st ABG (min)

pH

pCO2

pO2

BE

AaDO2

PaO2/fiO2

Risk Factors: CPAP success vs.sFailure

Prenatal risk factors for CPAP failure vs. Success

Failure

N (%)

Success

N (%) OR (95% CI) p-value

Hypertension 30 (35.7) 58 (38.4) 0.89 (0.51, 1.55) 0.68

Antenatal steroids 79 (97.5) 141 (96.6) 1.40 (0.27, 7.39) 0.69

PPROM>18 hrs 21 (25) 58 (38.4) 0.53 (0.30, 0.97) *0.04

Clinical chorio 18 (25.4) 27 (19.7) 1.38 (0.70, 2.73) 0.35

Intrapartum Antibiotics 36 (42.9) 86 (58.1) 0.54 (0.31, 0.93) *0.03

Failure

n (%)

Success

n (%) OR (95% CI) p-value

Multiple birth 41 (48.8) 57 (38) 1.57 (0.92, 2.70) 0.10

BWT<750 g 51 (60.7) 59 (39) 2.41 (1.40, 4.16) *0.00

Apgar <5 (1min) 25 (29.8) 39 (26) 0.82 (0.45, 1.49) 0.52

Apgar <5 (5min) 5 (6) 4 (3) 2.33 (0.61, 8.91) 0.21

Severe RDS (CXR) 27 (32 6 (4) 11.5 (4.49, 29.2) *0.00

Prenatal risk factors for CPAP failure vs. Success

Failure (84) Success (151) P-value*

GA (wks) 25. 7 (1.2) 26.8 (1.9) <0.001

BWT (g) 730 (122) 803 (128) <0.001

Initial fiO2 (%) 0.48 (26) 0.40 (27) 0.001

pH 7.30 (0.9) 7.33 (0.7) <0.001

pCO2 47 (16) 43 (11) 0.002

pO2 59 (44) 83 (60) <0.001

AaDO2 216 (175) 159 (187) 0.007

*Mann-Whitney test. Median (SD) tabulated.

Early Postnatal Risk Factors for CPAP Failure

Logistic Regression Analysis

OR

95% C.I.for OR

p-valueLower Upper

Intrapartum antibiotics .24 .10 .93 .001

GA .53 .39 .73 <.001

Severe RDS (CXR) 10.8 3.7 31.0 <.001

pH .00 .00 .007 .04

pO2/FiO2 .993 .988 .998 .007

Dependent variable is “CPAP failure”.

Predicting CPAP failure

• Do we want to emphasize sensitivity or specificity?

• Do we want to: (sensitivity)

– Not miss anyone who fails (greatly increasing the number of

babies who are intubated but who probably would have

succeeded on CPAP)?

Or should we (specificity)

– Identify and intervene in those babies highly likely to fail (but

missing the chance to help some who do)?

Performance of Associated Variables as

Predictors

Sensitivity Specificity PPV NPV

Intrapartum Antibiotics 42.9 41.9 29.5 43.6

Vaginal delivery 22.7 61.3 22.7 38.7

Severe RDS 32.1 96 81.8 28.2

GA≤26 wk 77.4 60.3 52 17.3

pH≤7.27 38.8 76.8 51.7 33.8

AaDO2>180 61.4 52.4 42.1 33.8

paO2/fiO2≤100 52.9 65.1 33.8 66.2

Performance of Composite Variables

Sensitivity Specificity PPV NPV

Severe RDS + (GA≤26 wk) 27.4 98.7 92 29

Severe RDS + (pH≤7.27) 10 99.2 88.9 37.1

Severe RDS + (AaDO2>180) 11.2 63.4 81.8 36.6

Severe RDS+ (paO2/fiO2≤100) 19.3 68.2 84.2 31.8

Summary

Based on the data from our NICU from the past

4 years (2008-11), if we have a baby with

• Severe RDS by CXR

The probability of CPAP failure is 82%.

With

• Severe RDS and (GA≤ 26 wks)

The probability of CPAP failure is 92%

These criteria will identify ¼-⅓ of the babies who actually fail.

Randomized Clinical Trials: CPAP vs. Intubation & Surfactant

COIN, CURPAP, SUPPORT, VON-DRM & Neocosur

Support Trial: Enrollment and Randomization

Inclusion Criteria 24 0/7 to 27 6/7 weeks: Stratified by gestational age n = 1316

Randomization occurred antenatally

Intubation, surfactant ventilation < 1hr and rapid

extubation

Nasal CPAP at 5 cm H2OPlaced on CPAP in the DR

663 653

All infants were randomly assigned to treatment group, irrespective of whether they were

breathing spontaneously or had respiratory distress

N Engl J Med 362(21):1970, 2010

Major Outcomes

CPAP Surfactant Relative risk p value

Death or BPD (physiological) 47.8% 51.0% 0.95 (0.85-1.05) 0.3

(need for O2 at 36 weeks) 48.7% 54.1% 0.91 (0.83-1.01) 0.07

Number of days supplemental O2 62.2 65.3 0.03

Number of days ventilation 24.8 27.7 0.01

Air leak 6.8% 7.4% NS

Postnatal steroids 7.1% 13.2% <.001

*In post hoc analysis, rates of death were significantly lower in infants 24-256/7

VON Delivery Room Management (DRM) Groups

T Intubation, prophylactic surfactant administration with subsequent

stabilization on ventilator support (PS Group)

T Intubation, prophylactic surfactant administration and rapid

extubation to NCPAP (ISX Group)

T Early stabilization on NCPAP and selective intubation and surfactant

administration for clinical indications (NCPAP Group)

Gestational age 26+0 to 29+6 weeks

Study assignment was made prior to delivery

Von Delivery Room Management Trial

Death or CLD At 36 Weeks Post Menstrual Age

36.5% 28.5% 30.5%

36.5%

50

40

30

20

10

0

% C

as

es

Death or CLD

RR 0.78(95% CI 0.59, 1.03)

RR 0.83(95% CI 0.64, 1.09)

PS ISX NCPAP

28.5%30.5%

Rojas and Soll 2010 unpublished

VON-DRM

T In the nasal CPAP group 48% were managed without intubation and 54%

without surfactant.

Summary of CPAP Trials

Gestational age N Death or BPD Air-leaks

CPAP/control CPAP/control

T Support 240/7-276/7 1316 47.8%/51.1% 6.8%/7.4%

T COIN 250/7-286/7 610 33.9%/38.9% 9.1%/3.0%

T VON 266/7-296/7 648 29.6%/36.5% 4.8%/5.4%

T Neocosur 800-1500g 256 13.7%/19.2% 3.1%/5.6%

T CURPAP 250/7-286/7 208 21.0%/21.9% 4.9%/9.5%

Total 3038 29.2%/33.52% 5.7%/6.18%

Nasal CPAP: Generation of Positive Airway Pressure

TThreshold resistor exhalation valve

T Bubble CPAP

T Variable flow nasal CPAP devices (Infant flow Driver)

Bubble CPAP

T Bubble NPCPAP uses a column of water to provide the positive airway

pressure rather than a variable resistor valve.

Are Bubbles Really Better?

T Comparative study of “high bubbling” vs. “low bubbling” in 26, stable

preterm infants 24-32 weeks gestation.

TThere was no effect on TCO2, TCPO2, SaO2, HR or RR.

* Morley CJ et al Arch. Dis. Child. 90: F343, 2004

Bubble CPAP: Is the Noise Important? An in vitro studyPillow JJ & Travadi AN Pediatr. Res. 57: 826, 2005

r2 = 0.91

(mL/cmH2O)

2 LPM

6 LPM

10 LPM

0.05 0.1 0.2 0.5 1 2

10

5

2

1

0.5

Pre

ssu

re R

an

ge

(cm

H2O

)

Lung compliance influences the range of pressure oscillations

Bubble CPAP enhances lung volume and gas

exchange in preterm lambs

Pillow J, Hillman N, Moss TJM, Polglase, Bold G, Beaumont, C Ikegami M & AH Jobe AJRCCM 2008

T Preterm lambs (133 days gestation) were intubated and randomized to

bubble CPAP (8 or 12 liters/min) or constant pressure CPAP (ventilator).

*

Time (min)

***

Bubble CPAPConstant Pressure CPAP

7.5

7.4

7.3

7.2

7.1

7.0

pH

0 30 60 90 120 150

Time (min)

0 30 60 90 120 150

Pa

CO

2(m

mH

g)

100

80

60

40

20

0

* ***

Bubble CPAP enhanced ventilation


*

Bubble CPAPConstant Pressure CPAP

Pa

O2

(mm

Hg

)400

300

200

100

0

Time (min)

0 30 60 90 120 150

Bubble CPAP improved oxygenation


A

% O

2e

xtr

ac

tio

n

10

8

6

4

2

0Bubble

12 L/minConstantPressure

p=0.041

Bubble8 L/min

p=0.045

Bubble CPAP enhanced O2 extraction


TThe more efficient utilization of inspired O2 in the bubble CPAP groups are

suggestive of increased airway patency.

T “Promotion of airway opening events likely explains the short term

improvement in respiratory physiology”.

Physiological Explanation of the Advantages of Bubble CPAP

10

VT

(mL

/kg

)

5

0ConstantPressure

Bubble8 L/min

Bubble12 L/min

p=0.04

TThis does not exclude a direct effect of the pressure oscillations

600

400

0ConstantPressure

Bubble8 L/min

Bubble12 L/min

p=0.041

MV

(m

L/k

g/m

in)


Randomized controlled Trial of Post-extubation Bubble CPAP

vs. Infant Flow Driver in Preterm Infants with RDS

Gupta S et al J Pediatr. 154: 645, 2009

T 140 infants at 24-29 weeks gestation were randomized to IFD-CPAP or B-CPAP.

Primary outcome was successful extubation for at least 72 hours.

T Although the proportion of infants in both groups who achieved successful

extubation for 72 hours was similar, the median duration of CPAP support was 50%

shorter in infants receiving bubble CPAP.

0

10

20

30

40

50

60

70

80

14.1%

Ventilated for ≤14 days

28.6%

Bubble CPAP

IFD CPAP

p=0.046

%*

IFD CPAPBubble CPAP

1.0

0.8

0.6

0.4

0.2

0.0

Cu

m S

urv

iva

l

Days CPAP Use

0 10 20 30 40 50 60

*% CPAP failure

Randomized controlled Trial of Post-extubation Bubble CPAP vs. Infant Flow Driver in Preterm Infants with RDS

Gupta S et al J Pediatr. 154: 645, 2009

High Flow Nasal Cannula

� Suggested as an alternative to CPAP that may be more comfortable

and avoids nasal septum irritation

� May be associated with an increased rick of mucosal irritation.

possibly increasing the risk of a healthcare associated infection

� PEEP is not measured and highly variable

� Limited data to support its efficacy or safety (Cochrane Review

2011)

Nasal Intermittent Positive Pressure Ventilation (NIPPV)

� Most centers are using non-synchronized NIPPV and there may be

no advantage to synchronized NIPPV (J Perinatology November

2011)

� In 6 small randomized trials, the rate of post-extubation failure

was lower with NIPPV than NCPAP

� In a large randomized clinical trial* early NIPPV did not decrease

the need for mechanical ventilation vs. NCPAP (most infants

received surfactant).

*Pediatrics, January 2011

T When mechanical ventilation is likely, surfactant should be administered soon

after birth (followed by rapid extubation).

T If the probability is that mechanical ventilation will not be necessary, surfactant

should be withheld.

T Those probabilities (and thresholds) will vary from nursery to nursery.

INSUREThoughts and Personal Biases

Cerebral outcomesPulmonary outcomes

RCT of extubation to CPAP at 24 hours or 5 days in preterm baboons

Thomson M et al Pediatrics 118: 2038, 2006

Clinical Recommendation

T Preterm infants with RDS weighing < 1500 gms. should be allowed time to

demonstrate if they can achieve acceptable ventilation and oxygenation on

CPAP. During that time period, these infants must be monitored closely. If

ventilation is not improving or oxygenation is worsening, or inadequate with

an FiO2 of 60%, these infants should be intubated.

T Should infants < 26 weeks gestation receive prophylactic surfactant?

cpap and rds: are we finally on the road to enlightenment?

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