Elsevier

The Journal of Pediatrics

Volume 147, Issue 3, September 2005, Pages 341-347
The Journal of Pediatrics

Original Article
Variables Associated with the Early Failure of Nasal CPAP in Very Low Birth Weight Infants

https://doi.org/10.1016/j.jpeds.2005.04.062Get rights and content

Objective

To identify risk factors and neonatal outcomes associated with the early failure of “bubble” nasal continuous positive airway pressure (CPAP) in very low birth weight (VLBW) infants with respiratory distress syndrome (RDS).

Study design

Following resuscitation and stabilization at delivery, a cohort of 261 consecutively inborn infants (birth weight ≤1250 g) was divided into three groups based on the initial respiratory support modality and outcome at 72 hours of age: “ventilator-started” group, “CPAP-failure” group, and “CPAP-success” group.

Results

CPAP was successful in 76% of infants ≤1250 g birth weight and 50% of infants ≤750 g birth weight. In analyses adjusted for postmenstrual age (PMA) and small for gestational age (SGA), CPAP failure was associated with need for positive pressure ventilation (PPV) at delivery, alveolar-arterial oxygen tension gradient (A-a DO2) >180 mmHg on the first arterial blood gas (ABG), and severe RDS on the initial chest x-ray (adjusted odds ratio [95% CI] = 2.37 [1.02, 5.52], 2.91 [1.30, 6.55] and 6.42 [2.75, 15.0], respectively). The positive predictive value of these variables ranged from 43% to 55%. In analyses adjusted for PMA and severe RDS, rates of mortality and common premature morbidities were higher in the CPAP-failure group than in the CPAP-success group.

Conclusion

Although several variables available near birth were strongly associated with early CPAP failure, they proved weak predictors of failure. A prospective controlled trial is needed to determine if extremely premature spontaneously breathing infants are better served by initial management with CPAP or mechanical ventilation.

Section snippets

Methods and Design

“Bubble” nasal CPAP is routinely used at the Children's Hospital of New York, Columbia University as an initial respiratory support modality in spontaneously breathing VLBW infants with RDS. Following resuscitation (if needed) and stabilization at delivery, VLBW infants are immediately carried to the transitional nursery within the delivery suite, where CPAP is applied to those with spontaneous respiratory effort within 5 to 10 minutes of birth.1 The initial respiratory support modality for

Statistical Analysis

To characterize the risks for early CPAP failure, three comparisons were made based on the infant's initial and eventual respiratory care group: ventilator-started versus CPAP-started; ventilator-started versus CPAP failure; and CPAP failure versus CPAP success. Because many of the variables used are not normally distributed, median values and their corresponding 95% CI for each group are reported.13 P values for post hoc comparisons were obtained from individual comparisons using Mann-Whitney

Respiratory Care Groups

Following initial resuscitation and stabilization in the delivery room and the transitional nursery, 229 (88%) infants were placed on nasal CPAP (the CPAP-started group) and 32 (12%) infants were started on mechanical ventilation (the ventilator-started group) as initial respiratory support modalities. Of ventilator-started infants, 29 of 32 (91%) underwent endotracheal intubation in the delivery room; the remaining three infants underwent endotracheal intubation on admission to the

Discussion

Progress in neonatal intensive care is closely related to improvements in the management of respiratory failure in small infants. Current modalities of ventilatory assistance range from CPAP to various modes of mechanical ventilation. The advent of less invasive methods of delivering CPAP to infants with RDS is associated with reduced need for intubation and mechanical ventilation and a lower incidence of CLD.1, 15, 16 The clinical outcomes for infants who succeed on CPAP are excellent, with

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