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Perspective on the paper by Booth et al (see page398)
There is currently a great dilemma regarding the early management of extremely low birthweight (ELBW) infants, which involves the use of continuous positive airway pressure (CPAP) after delivery compared with the use of prophylactic or early surfactant. Although there is good evidence that prophylactic and early surfactants reduce mortality and respiratory morbidity,1–4 few of these studies had large numbers of the smallest babies who are the longest-term residents of our neonatal intensive care units; also, none of the studies randomised infants in the placebo or control group to treatment with early CPAP. In addition, surfactant treatment may be associated with a lowered rate of milder disabilities at 1 year of age.5 The use of mechanical ventilation, especially in the first few days of life, seems to considerably increase the risk for bronchopulmonary dysplasia as defined by the need for oxygen at 36 weeks,6,7 and the incidence of bronchopulmonary disease (BPD) may be increasing in the most premature infants8,9 with a lesser incidence of the most severe forms of this disorder.10 There is an established association between the occurrence and severity of BPD and later neurodevelopmental disabilities.11–15 In our current quandary, is it better to avoid mechanical ventilation in the most vulnerable of preterm infants to circumvent the effects of intubation and baro-volutrauma and not administer early surfactants by using early CPAP, or do the benefits of intubation with the administration of early surfactant outweigh any subsequent morbidities seen with the use of CPAP?
Gregory et al16 showed that CPAP improved oxygenation in the presurfactant era for infants with respiratory distress and that CPAP was able to help in the establishment and maintenance of functional residual capacity. Subsequent …
Competing interests: Dr Finer is the principal investigator for the SUPPORT.
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