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Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial
  1. Nicolas A Bamat1,2,
  2. Carolyn M Orians1,
  3. Soraya Abbasi1,2,
  4. Colin J Morley3,
  5. Rob Ross Russell4,
  6. Howard B Panitch2,5,
  7. Sara C Handley1,2,
  8. Elizabeth E Foglia1,2,
  9. Michael A Posencheg1,2,
  10. Haresh Kirpalani1,2
  1. 1 Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  2. 2 Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  3. 3 Obstetrics, University of Cambridge, Cambridge, UK
  4. 4 Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  5. 5 Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
  1. Correspondence to Dr Nicolas A Bamat, Divison of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; bamatn{at}


Objective To measure within-subject changes in ventilation/perfusion (V′/Q′) mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.

Design Single-arm, non-randomised, feasibility trial.

Setting Three centres in the Children’s Hospital of Philadelphia neonatal care network.

Patients Twelve preterm infants of postmenstrual age 27–35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO2) >0.25 on CPAP of 4–7 cm H2O.

Interventions We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V′/Q′ mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V′/Q′ improved by more than 5%.

Main outcome measures Within-subject change in V′/Q′ mismatch between baseline and best CPAP levels.

Results There was a median (IQR) within-subject reduction in V′/Q′ mismatch of 1.2 (0–3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5–8) cm H2O.

Conclusions Non-invasive measures of V′/Q′ mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.

Trial registration number NCT02983825.

  • neonatology
  • respiratory medicine
  • physiology

Data availability statement

Data are available upon reasonable request. Please contact corresponding author.

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Data availability statement

Data are available upon reasonable request. Please contact corresponding author.

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  • Twitter @nbamat, @sara_c_handley

  • Contributors Study conception: NB, SA, CJM, RRR, HBP, HK. Study design: NB, SA, CJM, RRR, HBP, EEF, MP, HK. Data acquisition: NAB, CMO, SA, SH. Data analysis: NB, CMO. Data interpretation: NB, HK. Drafting the work: NAB. Revising it for critically important intellectual content: All authors. NB is gurantor.

  • Funding This work was supported by The Gerber Foundation Novice Research Grant and the Thrasher Foundation Early Career Award Program. NB was supported by National Institute of Child Health and Human Development grant K23HD10165 during the drafting of this manuscript. The funders played no role in the design, conduct or reporting of this study.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.