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Nasal continuous positive airways pressure (NCPAP) reduces duration of ventilation and extubation failure in preterm infants with respiratory distress.1 Although starting preterm infants on NCPAP without prior ventilation (ie, primary treatment of respiratory distress) is as effective a strategy as routine ventilation2 and surfactant,3 NCPAP is rarely used in this way in the UK (reportedly 2% of units).4 A systematic review of interfaces and pressure sources found binasal prongs to be more effective than a single prong.5 A superior pressure source was not identified, although a recent randomised trial found advantages with bubble NCPAP (Fisher & Paykel Healthcare, Auckland, New Zealand) compared to the Infant Flow Driver (Viasys, Warwick UK).6 Nasal intermittent positive pressure ventilation (NIPPV) is widely used in the UK.7 Small studies of NIPPV given with a ventilator delivering inflations with pressures ≥10 cm H2O demonstrated reductions in extubation failure and apnoea compared to NCPAP.8 9
Of the 30 delivery units in Ireland (20 in the Irish Republic, 10 in Northern Ireland), 28 have an on-site nursery. Infants are routinely ventilated in 12 units; infants ventilated in the remaining 16 are transferred to one of these 12 units. In July 2009 we surveyed a consultant and a senior nurse in each of the 28 nurseries by post. We sought information about the unit, whether NCPAP was used, for what clinical indication(s) and patient groups NCPAP was used, what pressure sources and interfaces were used, and whether NIPPV was used.
Replies were received from doctors and nurses in all units (median (range) number of deliveries 2550 (1200–9000) and cots 15 (4–39)). NCPAP was used in 24/28 units (see table 1). It was given as primary treatment for infants ≤28 weeks in 17 units – including five where infants were not routinely ventilated – and for infants ≤26 weeks in nine units. The Infant Flow Driver was used in 22/24 (92%) units and bubble CPAP in 5/24 (21%) units. Short binasal prongs were used in all units and nasal masks in 18/24 (75%) units. NIPPV was given to infants in 17 units. The Infant Flow SiPAP (Viasys) was used in 15/24 (63%), including seven where infants were not routinely ventilated.
CPAP is widely used for primary treatment of respiratory distress in preterm infants in Ireland. Many extremely preterm infants who start on NCPAP are, however, ultimately ventilated (46% in the COIN2 and 83% in the SUPPORT3 studies). While the use of NCPAP in non-tertiary centres may be beneficial, it should not be a substitute for or delay the transfer of extremely preterm infants to a tertiary centre. The studies that show a benefit of NIPPV used machines which are now obsolete.7 8 The Infant Flow SiPAP has not been evaluated in randomised trials and delivers inflations with a peak pressure ≤10 cm H2O. It is, thus, widely used with little evidence to support its efficacy. As in the UK,7 although short binasal prongs are the favoured interface, nasal masks are widely used. While both interfaces appear to injure the nose with equal frequency,10 their efficacy has not been directly compared. Our results illustrate the need for further studies in this area.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.