Early nCPAP in preterm neonates negates intubation, surfactant
MedWire News: Preterm neonates managed with either nasal continuous positive airway pressure (nCPAP) or prophylactic surfactant (PS) with rapid extubation to nCPAP have similar clinical outcomes to those treated with PS followed by mechanical ventilation, study results show.
Notably, in the nCPAP group around half of neonates were managed without intubation and ventilation or surfactant treatment.
"Even if considered equivalent, many would advocate using this approach as a means of providing a less invasive method of support," study co-author Michael Dunn (Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada) and colleagues comment.
The majority of neonates born at less than 30 weeks' gestation require respiratory support after birth to facilitate transition and ensure adequate gas exchange.
"The best approach to the initial respiratory management of these infants is uncertain," Dunn et al comment.
Over the past decade, many trials have demonstrated the feasibility and apparent benefits of providing early nCPAP, and studies have also revealed that surfactant can be effectively administered to many infants initially managed with nCPAP, with a brief period of endotracheal intubation followed by rapid extubation back to nCPAP.
For the current study, the researchers recruited 648 preterm neonates delivered at 26+0-29+6 weeks' gestation from 28 centers in the Vermont Oxford Network.
Primary outcome was the incidence of death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age.
Three approaches to initial respiratory management were compared: PS followed by a period of mechanical ventilation (PS); PS with rapid extubation to bubble nCPAP (intubate-surfactant-extubate [ISX]); or initial management with bubble CPAP and selective surfactant treatment (nCPAP).
Random assignment took place when it was deemed that delivery was imminent. Women who were carrying a fetus with a potentially life-threatening anomaly or condition were excluded.
Dunn et al report that there were no statistically significant differences in mortality or other complications of prematurity, largely owing to the fact that the study was halted before the desired sample size was reached because of declining enrolment.
Nevertheless, when compared with the PS group, the relative risk for BPD or death was 0.78 for the ISX group and 0.83 for the nCPAP group.
Dunn et al comment: "Prophylactic treatment results in a significant number of infants receiving treatment who seem to be able to do just as well without it, particularly those exposed to antenatal steroids."
"However, attempts to provide initial respiratory support with nCPAP should not result in infants with significant RDS being disadvantaged by having surfactant withheld or administration delayed," they add.
The research is published in the journal Pediatrics.
By Andrew Czyzewski