Abstract
Continuous positive airway pressure (CPAP) is widely used in neonatal units both as a primary mode of respiratory support and following extubation from mechanical ventilation. In this review, the evidence for CPAP use particularly in prematurely born infants is considered. Studies comparing methods of CPAP generation have yielded conflicting results, but meta-analysis of randomised trials has demonstrated that delivering CPAP via short nasal prongs is most effective in preventing re-intubation. At present, there is insufficient evidence to establish the safety or efficacy of high flow nasal cannulae for prematurely born infants. Observational studies highlighted that early CPAP use rather than intubation and ventilation was associated with a lower incidence of bronchopulmonary dysplasia (BPD), but this has not been confirmed in three large randomised trials. Meta-analysis of the results of randomised trials has demonstrated that use of CPAP reduces extubation failure, particularly if a CPAP level of 5 cm H2O or more is used. Nasal injury can occur and is related to the length of time CPAP is used; weaning CPAP by pressure rather than by “time-cycling” reduces the weaning time and may reduce BPD. In conclusion, further studies are required to identify the optimum mode of CPAP generation and it is important that prematurely born infants are weaned from CPAP as soon as possible.
Similar content being viewed by others
Introduction
Infants create positive end-expiratory pressure by grunting to try and prevent atelectasis [23]. Gregory et al. [21] used that principle to develop continuous positive airway pressure (CPAP) and described its first successful use in neonates. Since then, the use of CPAP has become widespread. CPAP can increase functional residual capacity thereby improving oxygenation [47], reduce airway resistance and the work of breathing, stabilise the chest wall enhancing respiratory thoraco-abdominal synchrony [35], improve diaphragmatic function [4] and reduce upper airway resistance decreasing obstructive apnoea [37, 38]. CPAP, however, does have side effects, such as ‘CPAP belly syndrome’ [27], nasal irritation and skin damage [63], and nasal deformities if CPAP use is prolonged [48]. There are different methods of CPAP generation and delivery and CPAP is now used to support prematurely born infants at different stages in their respiratory illness. The aim of this review is to critically analyse the literature to determine if there is sufficient evidence to determine the optimum method of CPAP generation or delivery and when prematurely born infants would most benefit from CPAP.
Methods of CPAP generation
Devices which generate CPAP can broadly be divided into two categories, continuous flow or variable flow devices. Continuous flow devices include conventional ventilators, jet ventilation systems and bubble CPAP. Conventional ventilators provide a constant flow of gas and the pressure is controlled by the exhalation valve. With a jet system, a small jet is produced either at the nostrils or in a prechamber in front of the nasal prongs. During bubble CPAP, the pressure is set by immersing the expiratory limb of the CPAP device in an underwater chamber to a depth equal to the desired CPAP level. The gas flows through the system causing bubbling in the chamber; this causes variability in the mean CPAP pressure. Using a variable flow device, the CPAP level is dependent on the flow of gas.
High-flow nasal cannulae (HFNC) are small, thin, tapered cannulae which deliver flows in excess of 1 L/min [61]. HFNC may deliver positive end-expiratory pressure [19]. There have been four randomised or quasi-randomised trials which were included in a Cochrane review [61]. In one trial [42], HFNC (Vapotherm ®) was compared to bubble CPAP in infants requiring CPAP in the first 6 h after birth, no significant difference was found in the requirement for intubation (RR 1.03; 95% CI 0.28, 3.78). In a second study [9], HFNC compared to nasal CPAP post-extubation was associated with a significantly higher rate of re-intubation (RR 4.00; 95% CI 1.33, 12.05). In a further study [62], Vapotherm ® performed better than standard unhumidified high flow nasal cannula with regard to maintaining a normal appearing nasal mucosa, a lower respiratory effort score and averting reintubation. In the fourth trial [39], two different HFNC delivery systems (Vapotherm ® and Fisher and Paykel) post-extubation were compared in 40 infants, no significant difference was found in the rate of extubation failure. The Cochrane review [61] concluded that the trials differed in their design and interventions, such that meta-analysis was not possible and, at present, there is insufficient evidence to establish the safety or efficacy of HFNC for prematurely born infants.
There have been few randomised trials comparing methods of CPAP generation, the majority are of crossover design (Table 1). The results of those studies have suggested that variable-flow CPAP has advantages over ventilator-delivered CPAP being associated with lower duration of supplementary oxygen, length of stay and work of breathing and greater stability of flow and tidal volume [25, 44, 54]. In subgroup analysis of infants ventilated for less than 2 weeks, bubble CPAP compared to variable-flow CPAP was associated with a significantly lower rate of extubation failure, as well as a significantly reduced duration of CPAP, but overall, there were no significant differences in the rates of successful extubation [22]. In a smaller randomised crossover study, bubble compared to variable-flow CPAP was associated with significantly greater work of breathing, respiratory rate and thoraco-abdominal asynchrony [34].
CPAP delivery
Short binasal prongs and nasal masks are two of the most commonly used interfaces for delivering CPAP [30]. Other delivery methods include via a nasopharyngeal prong, an endotracheal tube and a helmet. Short binasal prongs impose a lower work of breathing compared to nasopharyngeal prongs [31, 40]. The results of a meta-analysis highlighted that binasal prongs were more effective in preventing reintubation in prematurely born infants when compared to either single nasal or nasopharyngeal prongs (RR 0.59, 95% CI 0.41–0.85) [16]. Nasal injury following CPAP delivered by short nasal prongs has been documented [48]. In a randomised study of 89 very low-birthweight infants, in which nasal prongs were compared to nasal mask, no significant difference in the incidence of nasal injury was demonstrated, but the incidence of nasal injury was significantly associated with the duration of CPAP [63].
In a short-term randomised crossover study, ‘helmet’ CPAP was found to be as effective as nasal CPAP with respect to oxygen requirement, oxygen saturation, heart rate, respiratory rate, mean arterial blood pressure and transcutaneous carbon dioxide. In addition, helmet CPAP use was associated with a significant increase in infant comfort assessed by the Neonatal Infant Pain Scale [59]. There are, however, concerns that it may adversely affect cerebral blood flow [64] and it is associated with significantly higher noise levels than nasal CPAP [58].
CPAP for initial respiratory support
Avery et al.’s survey of eight tertiary neonatal centres in the USA [6] demonstrated that the centre which used CPAP as initial respiratory support had the lowest rate of bronchopulmonary dysplasia (BPD) compared to centres in which the initial mode was intubation and ventilation. A subsequent, retrospective study showed that Columbia’s primary CPAP approach continued to be associated with a lower rate of BPD compared to that seen in centres which favoured mechanical ventilation and surfactant administration [60]. Other observational studies have highlighted that use of early CPAP was associated with significantly less need for intubation and ventilation [2, 15, 20, 26, 36, 43] and surfactant therapy [1, 15] and lower incidences of intraventricular haemorrhage (IVH) [3, 26, 33] and BPD [2, 3, 7, 15, 33, 36].
There have been a number of randomised trials comparing early CPAP to other respiratory mode strategies. In a small randomised study [12] of 27 infants of less than 30 weeks of gestation, prophylactic surfactant followed by immediate extubation to CPAP compared to prophylactic surfactant followed by mechanical ventilation was associated with less need for mechanical ventilation at 7 days (p = 0.026). The CPAP group also had significantly lower durations of supplementary oxygen, CPAP and mechanical ventilation, less need for a second dose of surfactant and a shorter duration of intensive care, but there were no significant differences in death or BPD at 28 days or 36 weeks postmenstrual age (PMA). Sandri et al. [49] compared prophylactic to rescue CPAP in a randomised study of 230 infants born between 28 and 31 weeks of gestation, who did not require intubation in the delivery room. No significant differences were found in the need for surfactant therapy or mechanical ventilation or the incidence of air leaks. There was a trend towards an increased risk of IVH grades 3–4 (RR 3.0, 95% CI 0.96, 28.42) in the early CPAP group. Three recently published randomised trials have assessed early CPAP [41, 50, 55] and only one reported a reduced risk of death or BPD but only at 28 days and not 36 weeks PMA (Table 2). In the COIN trial [41], the combined outcome of BPD or death was lower in the CPAP group at 28 days (OR 0.63; 95% CI, 0.46–0.88; p = 0.006), but not at 36 weeks PMA (OR 0.76; 95% CI, 0.54–1.09). A significantly lower proportion of the CPAP group required surfactant therapy (38% vs. 77%, p < 0.001) and the infants in the CPAP group required fewer days on mechanical ventilation (3 vs. 4 days, p < 0.001). The CPAP group, however, had a significantly increased incidence of pneumothorax (9.1% vs. 3%, p = 0.001), which might relate to the CPAP pressure of 8 cm H2O or the lower use of prophylactic surfactant. In the SUPPORT trial [55], there was no significant difference in the primary outcome of death or BPD, although there was higher postnatal steroid use in the intubation–surfactant group (13.2% vs. 7.2%, p < 0.001). The CPAP group required significantly less days of mechanical ventilation (p = 0.03) and had a significantly higher rate of survival free of mechanical ventilation at 7 days (RR 1.14, 95% CI, 1.03–1.25). In the CURPAP trial [50], no significant difference was found in the primary outcome, the need for mechanical ventilation in the first 5 days or in the secondary outcomes including death, BPD, air leaks, grades 3–4 IVH, sepsis, retinopathy of prematurity and pulmonary haemorrhage.
CPAP following extubation
Meta-analysis of the results of nine randomised trials (Table 3) highlighted that extubation to nasal CPAP rather than into headbox oxygen was associated with a decreased incidence of respiratory failure defined as respiratory acidosis, apnoea or an increased oxygen requirement needing additional ventilatory support (RR 0.62, 95% CI 0.51–0.76) [14]. In a subgroup analysis, in the trials in which CPAP levels of 5 cm H2O or greater were used, CPAP significantly reduced extubation failure (RR 0.49 (95% CI 0.37–0.66)) [5, 13, 18, 24, 52].
Weaning from CPAP
A survey of 58 neonatal units in the North of England [8] revealed that only 3 units had a weaning protocol. Some respondents practised abrupt discontinuation of CPAP, but the majority of units (66%) weaned by ‘time off’, 4% by weaning pressure and 30% indicated no set method. In a survey of 124 Australian tertiary neonatal units [28], 70% of respondents reported using graded time off CPAP as part of weaning; 74% of all respondents (whether using graded time off or not) replied that they gradually reduced the airway pressure before coming off CPAP. Three randomised controlled trials have examined different methods of weaning CPAP [51, 53, 57], two have been reported only as abstracts (Table 4). Weaning by reduction in pressure rather than by time cycling was associated with a shorter duration of weaning, less days on CPAP and a lower incidence of chronic lung disease [51, 53].
References
Aly H, Massaro AN, Patel K, El-Mohandes AA (2005) Is it safer to intubate premature infants in the delivery room? Pediatrics 115:1660–1665
Aly H, Milner JD, Patel K, El-Mohandes AA (2004) Does the experience with the use of nasal continuous positive airway pressure improve over time in extremely low birth weight infants? Pediatrics 114:697–702
Ammari A, Suri M, Milisavljevic V, Sahni R, Bateman D, Sanocka U, Ruzal-Shapiro C, Wung JT, Polin RA (2005) Variables associated with the early failure of nasal CPAP in very low birth weight infants. J Pediatr 147:341–347
Andréasson B, Lindroth M, Svenningsen NW, Jonson B (1988) Effects on respiration of CPAP immediately after extubation in the very preterm infant. Pediatr Pulmonol 4:213–218
Annibale DJ, Hulsey TC, Engstrom PC, Wallin LA, Ohning BL (1994) Randomized, controlled trial of nasopharyngeal continuous positive airway pressure in the extubation of very low birth weight infants. J Pediatr 124:455–460
Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB, Epstein MF, Fitzhardinge PM, Hansen CB, Hansen TN et al (1987) Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics 79:26–30
Birenbaum HJ, Dentry A, Cirelli J, Helou S, Pane MA, Starr K, Melick CF, Updegraff L, Arnold C, Tamayo A, Torres V, Gungon N, Liverman S (2009) Reduction in the incidence of chronic lung disease in very low birth weight infants: results of a quality improvement process in a tertiary level neonatal intensive care unit. Pediatrics 123:44–50
Bowe L, Clarke P (2005) Current use of nasal continuous positive airways pressure in neonates. Arch Dis Child Fetal Neonatal Ed 90:F92–F93
Campbell DM, Shah PS, Shah V, Kelly EN (2006) Nasal continuous positive airway pressure from high flow cannula versus infant flow for preterm infants. J Perinatol 26:546–549
Chan V, Greenough A (1993) Randomised trial of methods of extubation in acute and chronic respiratory distress. Arch Dis Child 68:570–572
Courtney SE, Kahn DJ, Singh R, Habib RH (2011) Bubble and ventilator-derived nasal continuous positive airway pressure in premature infants: work of breathing and gas exchange. J Perinatol 31:44–50
Dani C, Bertini G, Pezzati M, Cecchi A, Caviglioli C, Rubaltelli FF (2004) Early extubation and nasal continuous positive airway pressure after surfactant treatment for respiratory distress syndrome among preterm infants <30 weeks’ gestation. Pediatrics 113:e560–e563
Davis P, Jankov R, Doyle L, Henschke P (1998) Randomised, controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g. Arch Dis Child Fetal Neonatal Ed 79:F54–F57
Davis PG, Henderson-Smart DJ (2003) Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database Syst Rev 2:CD000143
De Klerk AM, De Klerk RK (2001) Nasal continuous positive airway pressure and outcomes of preterm infants. J Paediatr Child Health 37:161–167
De Paoli AG, Davis PG, Faber B, Morley CJ (2008) Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev 1:CD002977
Dimitriou G, Greenough A, Kavvadia V, Laubscher B, Alexiou C, Pavlou V, Mantagos S (2000) Elective use of nasal continuous positive airways pressure following extubation of preterm infants. Eur J Pediatr 159:434–439
Engelke SC, Roloff DW, Kuhns LR (1982) Postextubation nasal continuous positive airway pressure. A prospective controlled study. Am J Dis Child 136:359–361
Frey B, McQuillan PJ, Shann F, Freezer N (2001) Nasopharyngeal oxygen therapy produces positive end-expiratory pressure in infants. Eur J Pediatr 160:556–560
Gittermann MK, Fusch C, Gittermann AR, Regazzoni BM, Moessinger AC (1997) Early nasal continuous positive airway pressure treatment reduces the need for intubation in very low birth weight infants. Eur J Pediatr 156:384–388
Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK (1971) Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N Engl J Med 284:1333–1340
Gupta S, Sinha SK, Tin W, Donn SM (2009) A randomized controlled trial of post-extubation bubble continuous positive airway pressure versus Infant Flow Driver continuous positive airway pressure in preterm infants with respiratory distress syndrome. J Pediatr 154:645–650
Harrison VC, Heese Hde V, Klein M (1968) The significance of grunting in hyaline membrane disease. Pediatrics 41:549–559
Higgins RD, Richter SE, Davis JM (1991) Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates. Pediatrics 88:999–1003
Huckstadt T, Foitzik B, Wauer RR, Schmalisch G (2003) Comparison of two different CPAP systems by tidal breathing parameters. Intensive Care Med 29:1134–1140
Jacobsen T, Grønvall J, Petersen S, Andersen GE (1993) “Minitouch” treatment of very low-birth-weight infants. Acta Paediatr 82:934–938
Jaile JC, Levin T, Wung JT, Abramson SJ, Ruzal-Shapiro C, Berdon WE (1992) Benign gaseous distension of the bowel in premature infants treated with nasal continuous airway pressure: a study of contributing factors. AJR Am J Roentgenol 158:125–127
Jardine L, Davies MW (2008) Withdrawal of neonatal continuous positive airway pressure: current practice in Australia. Pediatr Int 50:572–575
Kavvadia V, Greenough A, Dimitriou G (2000) Effect on lung function of continuous positive airway pressure administered either by infant flow driver or a single nasal prong. Eur J Pediatr 159:289–292
Kieran EA, Walsh H, O’Donnell CP (2011) Survey of nasal continuous positive airways pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) use in Irish newborn nurseries. Arch Dis Child Fetal Neonatal Ed 96:F156
Klausner JF, Lee AY, Hutchison AA (1996) Decreased imposed work with a new nasal continuous positive airway pressure device. Pediatr Pulmonol 22:188–194
Lee KS, Dunn MS, Fenwick M, Shennan AT (1998) A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation. Biol Neonate 73:69–75
Lindner W, Vossbeck S, Hummler H, Pohlandt F (1999) Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation? Pediatrics 103:961–967
Liptsen E, Aghai ZH, Pyon KH, Saslow JG, Nakhla T, Long J, Steele AM, Habib RH, Courtney SE (2005) Work of breathing during nasal continuous positive airway pressure in preterm infants: a comparison of bubble vs variable-flow devices. J Perinatol 25:453–458
Locke R, Greenspan JS, Shaffer TH, Rubenstein SD, Wolfson MR (1991) Effect of nasal CPAP on thoracoabdominal motion in neonates with respiratory insufficiency. Pediatr Pulmonol 11:259–264
Miksch RM, Armbrust S, Pahnke J, Fusch C (2008) Outcome of very low birthweight infants after introducing a new standard regime with the early use of nasal CPAP. Eur J Pediatr 167:909–916
Miller MJ, Carlo WA, Martin RJ (1985) Continuous positive airway pressure selectively reduces obstructive apnea in preterm infants. J Pediatr 106(1):91–94
Miller MJ, DiFiore JM, Strohl KP, Martin RJ (1990) Effects of nasal CPAP on supraglottic and total pulmonary resistance in preterm infants. J Appl Physiol 68:141–146
Miller SM, Dowd SA (2010) High-flow nasal cannula and extubation success in the premature infant: a comparison of two modalities. J Perinatol 30:805–808
Moa G, Nilsson K, Zetterström H, Jonsson LO (1988) A new device for administration of nasal continuous positive airway pressure in the newborn: an experimental study. Crit Care Med 16:1238–1242
Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB, Trial Investigators COIN (2008) Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 358:700–708
Nair G, Karna P (2005) Comparison of the effects of vapotherm and nasal CPAP in respiratory distress. PAS.1.
Narendran V, Morley CJ, Lau R, De Paoli A, Davis PG (2003) Early bubble CPAP and outcomes in ELBW preterm infants. J Perinatol 23:195–199
Pandit PB, Morley CJ, Lau R, De Paoli A, Davis PG (2001) Work of breathing during constant- and variable-flow nasal continuous positive airway pressure in preterm neonates. Pediatrics 108:682–685
Pantalitschka T, Sievers J, Urschitz MS, Herberts T, Reher C, Poets CF (2009) Randomised crossover trial of four nasal respiratory support systems for apnoea of prematurity in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 94:F245–F248
Peake M, Dillon P, Shaw NJ (2005) Randomized trial of continuous positive airways pressure to prevent reventilation in preterm infants. Pediatr Pulmonol 39:247–250
Richardson CP, Jung AL (1978) Effects of continuous positive airway pressure on pulmonary function and blood gases of infants with respiratory distress syndrome. Pediatr Res 12:771–774
Robertson NJ, McCarthy LS, Hamilton PA, Moss AL (1996) Nasal deformities resulting from flow driver continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 75:F209–F212
Sandri F, Ancora G, Lanzoni A, Tagliabue P, Colnaghi M, Ventura ML, Rinaldi M, Mondello I, Gancia P, Salvioli GP, Orzalesi M, Mosca F (2004) Prophylactic nasal continuous positive airways pressure in newborns of 28–31 weeks gestation: multicentre randomised controlled clinical trial. Arch Dis Child Fetal Neonatal Ed 89:F394–F398
Sandri F, Plavka R, Ancora G, Simeoni U, Stranak Z, Martinelli S, Mosca F, Nona J, Thomson M, Verder H, Fabbri L, Halliday H, CURPAP Study Group (2010) Prophylactic or early selective surfactant combined with nCPAP in very preterm infants. Pediatrics 125:e1402–e1409
Singh SD, Clarke P, Bowe L, Glover K, Pasquill A, Robinson MJ, Smith J (2006) Is decreasing pressure or increasing time off the better strategy in weaning VLBW infants from nasal CPAP. European Journal of Pediatrics, Book of Abstracts European Academy of Pediatrics 165:48
So BH, Tamura M, Mishina J, Watanabe T, Kamoshita S (1995) Application of nasal continuous positive airway pressure to early extubation in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 72:F191–F193
Soe A, Hodgkinson J, Jani B, Ducker DA (2006) Nasal continuous positive airway pressure weaning in preterm infants. European Journal of Paediatrics, Book of Abstracts European Academy of Paediatrics 165:48–49
Stefanescu BM, Murphy WP, Hansell BJ, Fuloria M, Morgan TM, Aschner JL (2003) A randomized, controlled trial comparing two different continuous positive airway pressure systems for the successful extubation of extremely low birth weight infants. Pediatrics 112:1031–1038
SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network (2010) Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 362:1970–1979
Tapia JL, Bancalari A, González A, Mercado ME (1995) Does continuous positive airway pressure (CPAP) during weaning from intermittent mandatory ventilation in very low birth weight infants have risks or benefits? A controlled trial. Pediatr Pulmonol 19:269–274
Todd D, Shadbolt B, Wright A, Chauhan M, Cameron C, Jardine L et al (2010) CPAP Weaning: impact on time of CPAP and oxygen duration? In: Abstracts of the 14th Annual Congress of the Perinatal Society of Australia and New Zealand 28–31 March 2010, Wellington, New Zealand. J Paediatr Child Health 46:A143
Trevisanuto D, Camiletti L, Doglioni N, Cavallin F, Udilano A, Zanardo V (2011) Noise exposure is increased with neonatal helmet CPAP in comparison with conventional nasal CPAP. Acta Anaesthesiol Scand 55:35–38
Trevisanuto D, Grazzina N, Doglioni N, Ferrarese P, Marzari F, Zanardo V (2005) A new device for administration of continuous positive airway pressure in preterm infants: comparison with a standard nasal CPAP continuous positive airway pressure system. Intensive Care Med 31:859–864
Van Marter LJ, Allred EN, Pagano M, Sanocka U, Parad R, Moore M, Susser M, Paneth N, Leviton A (2000) Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network. Pediatrics 105:1194–1201
Wilkinson D, Andersen C, O’Donnell CP, De Paoli AG (2011) High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 5:CD006405
Woodhead DD, Lambert DK, Clark JM, Christensen RD (2006) Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial. J Perinatol 26:481–485
Yong SC, Chen SJ, Boo NY (2005) Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: a randomised control study. Arch Dis Child Fetal Neonatal Ed 90:F480–F483
Zaramella P, Freato F, Grazzina N, Saraceni E, Vianello A, Chiandetti L (2006) Does helmet CPAP reduce cerebral blood flow and volume by comparison with Infant Flow driver CPAP in preterm neonates? Intensive Care Med 32:1613–1619
Acknowledgements
Dr. Olie Chowdhury is funded by the Charles Wolfson Charitable Trust. We thank Mrs. Deirdre Gibbons for the secretarial assistance.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chowdhury, O., Wedderburn, C.J., Duffy, D. et al. CPAP review. Eur J Pediatr 171, 1441–1448 (2012). https://doi.org/10.1007/s00431-011-1648-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-011-1648-6