Continuous Positive Airway Pressure Failure in Preterm Infants: Incidence, Predictors and Consequences

Abstract

Background: Preterm infants ≤32 weeks' gestation are increasingly being managed on continuous positive airway pressure (CPAP), without prior intubation and surfactant therapy. Some infants treated in this way ultimately fail on CPAP and require intubation and ventilation. Objectives: To define the incidence, predictors and consequences of CPAP failure in preterm infants managed with CPAP from the outset. Methods: Preterm infants 25-32 weeks' gestation were included in the study if inborn and managed with CPAP as the initial respiratory support, with division into two gestation ranges and grouping according to whether they were successfully managed on CPAP (CPAP-S) or failed on CPAP and required intubation <72 h (CPAP-F). Predictors of CPAP failure were sought, and outcomes compared between the groups. Results: 297 infants received CPAP, of which 65 (22%) failed, with CPAP failure being more likely at lower gestational age. Most infants failing CPAP had moderate or severe respiratory distress syndrome radiologically. In multivariate analysis, CPAP failure was found to be predicted by the highest FiO₂ in the first hours of life. CPAP-F infants had a prolonged need for respiratory support and oxygen therapy, and a higher risk of death or bronchopulmonary dysplasia at 25-28 weeks' gestation (CPAP-F 53% vs. CPAP-S 14%, relative risk 3.8, 95% CI 1.6, 9.3) and a substantially higher risk of pneumothorax at 29-32 weeks. Conclusion: CPAP failure in preterm infants usually occurs because of unremitting respiratory distress syndrome, is predicted by an FiO₂ ≥0.3 in the first hours of life, and is associated with adverse outcomes.

Effects of less-invasive surfactant administration on oxygenation, pulmonary surfactant distribution, and lung compliance in spontaneously breathing preterm lambs

“…However, the higher compliance in intubated lambs did not lead to better oxygenation. In our opinion, the most clinically relevant endpoint is oxygenation, since preterm infants who fail CPAP therapy show worse oxygenation during the first hours after birth (6,22). There are several limitations to this study.…”

“…In addition, mechanical ventilation can damage the vulnerable preterm lungs. It has been hypothesized that avoidance of mechanical ventilation might lead to less bronchopulmonary dysplasia (4,5), as infants that failed initial continuous positive airway pressure (CPAP) therapy and needed subsequent mechanical ventilation showed higher bronchopulmonary dysplasia rates (6).…”

Incidence and Outcome of CPAP Failure in Preterm Infants

“…Data from several hospital-based cohort studies strongly suggest that CPAP failure is primarily caused by untreated surfactant deficiency, and is associated with adverse outcomes, including increased risk of mortality as well as morbidities, including air leak, bronchopulmonary dysplasia (BPD), and intraventricular hemorrhage (IVH). [9][10][11][12][13][14] Reported studies of CPAP failure have involved relatively small cohorts of infants managed at 1 or 2 centers. [9][10][11][12][13][14] Examination of the effects of initial CPAP support and CPAP failure within largescale neonatal databases has been hampered by difficulty in identifying the exact sequence of respiratory management in early life within the reported data.…”

Respiratory Care of the Neonate

“…Therefore, the recent recommendations suggest an early less invasive surfactant administration before the neonate requires high proportions of oxygen in the inspired air [43]. If no improvement is seen after the first dose, the surfactant application is repeated for the second or third time.…”