CPAP from birth

There is an increasing body of evidence suggesting that continuous positive airway pressure (CPAP) given from birth, to achieve immediate and enduring functional residual capacity, is as effective a short term strategy in preterm babies as immediate intubation and administration of surfactant. The secondary question has been whether early CPAP may have the added benefit of reducing broncho-pulmonary dysplasia. Schmoölzer et al undertook a meta-analysis (BMJ 2013;347:f5980) that included 2782 participants in four randomised controlled trials (RCTs), and concluded that for infants under 32 weeks, one more infant could avoid oxygen dependency at 36 weeks post-menstrual age for every 25 managed with CPAP rather than being intubated. This is a powerful argument for a gradual move towards a strategy of early CPAP and away from the conventional approach of ‘intubate, give surfactant, ask questions afterwards’. Schmoölzer et al (above) did not specify the CPAP pressures used in the four trials they synthesised, but in each of them the pressures were 5, 5–7, 6–7 and 8 cm water. So we don't actually know the ‘best’ or ‘correct’ pressure for initiating CPAP …