Researchers from India and Australia compared the safety and efficacy of bubble (B) continuous positive airway pressure (CPAP) with ventilator-derived CPAP (VCPAP) in preterm infants. They conducted a randomized controlled trial and enrolled infants at <37 weeks gestation who developed respiratory distress within 6 hours of birth. Only infants who had an oxygen requirement of >30% and who had at least moderate retractions and/or grunting as determined by a Silverman-Anderson (SA) score >4 (range of possible scores 0–10) were eligible for enrollment. At enrollment, study infants were randomized to BCPAP or VCPAP. Commercial brand equipment was used for both groups, including a bubble generator and blender for BCPAP, ventilator equipment for VCPAP, and nasal prongs. Both groups were started on 40% FiO2 and a CPAP pressure of 6 cm of water (cmW). Based on clinical assessment and a goal of maintaining an oxygen saturation of 88% to 93%, FiO2 was changed in increments of 5% and CPAP in increments of 1 cmW. After 1 hour of CPAP support, surfactant replacement was administered to infants requiring ≥40% FiO2, ≥6 cmW CPAP, and having x-ray findings consistent with respiratory distress syndrome (RDS).
The primary study outcome was success of the allocated ventilation method. Success was defined as discontinuation of CPAP within 72 hours and no need for mechanical ventilation, oxygen requirement of <30%, and an SA score <3. Secondary outcomes included need for surfactant therapy, nasal injury from CPAP, and overall mortality.
One hundred and fourteen infants were enrolled, with 57 in each group. The groups were comparable at baseline with respect to gestational age, birth weight, and SA score.
Neonates treated with BCPAP were significantly more likely to have successful treatment than those randomized to VCPAP (82.5% and 63.2%, respectively, P = .3). Surfactant was given to more infants in the VCPAP than BCPAP group (18/57 vs 9/57, P < .05). Overall, infants who required surfactant were significantly less likely to have successful CPAP treatment, regardless of type of CPAP. VCPAP and BCPAP groups were comparable in terms of CPAP duration (30 hours and 36 hours, respectively) and mortality (8.8% and 7%, respectively). Injury to the nasal septum was more frequent in infants randomized to BCPAP (21.1%) than to those receiving VCPAP (7%) (P = .03).
The authors conclude that BCPAP is safe and more effective than VCPAP when used early for preterm neonates with moderate to severe RDS.
Drs Santisteban-Ponce and Bedrick have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
CPAP emerged in 1971 as an alternative to mechanical ventilation for preterm infants with RDS, reducing the need for intubation....