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CPAP OR INTUBATION AT BIRTH
Morley CA, Davis PG, Doyle LW, et al. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008;358:700-708 [Full Text] | [PDF]
Objective. Bronchopulmonary dysplasia is associated with ventilation and oxygen treatment. This randomized trial investigated whether nasal continuous positive airway pressure (CPAP), rather than intubation and ventilation, shortly after birth would reduce the rate of death or bronchopulmonary dysplasia in very preterm infants.
Methods. We randomly assigned 610 infants who were born at 25-to-28-weeks’ gestation to CPAP or intubation and ventilation at 5 minutes after birth. We assessed outcomes at 28 days of age, at 36 weeks’ gestational age, and before discharge.
Results. At 36 weeks’ gestational age, 33.9% of 307 infants who were assigned to receive CPAP had died or had bronchopulmonary dysplasia, as compared with 38.9% of 303 infants who were assigned to receive intubation (odds ratio favoring CPAP, 0.80; 95% confidence interval [CI], 0.58 to 1.12; P = 0.19). At 28 days, there was a lower risk of death or need for oxygen therapy in the CPAP group than in the intubation group (odds ratio, 0.63; 95% CI, 0.46 to 0.88; P = 0.006). There was little difference in overall mortality. In the CPAP group, 46% of infants were intubated during the first 5 days, and the use of surfactant was halved. The incidence of pneumothorax was 9% in the CPAP group, as compared with 3% in the intubation group (P<0.001). There were no other serious adverse events. The CPAP group had fewer days of ventilation.
Conclusions. In infants born at 25-to-28-weeks’ gestation, early nasal CPAP did not significantly reduce the rate of death or bronchopulmonary dysplasia, as compared with intubation. Even though the CPAP group had more incidences of pneumothorax, fewer infants received oxygen at 28 days, and they had fewer days of ventilation.
Comments. This is a large RCT (n=610) comparing early CPAP to intubation in the delivery room in preterm infants with a gestational age between 25 and 28 weeks. There was no difference in the primary outcome (death or BPD at 36 weeks: 33.9% and 38.9% in the CPAP and intubation groups, respectively). Although not reaching statistical significance, BPD in survivors was less common in the CPAP group (OR 0.76, 95% CI 0.54-1.09). On the other hand, half of the infants in the CPAP group were intubated during their NICU stay, and the incidence of pneumothorax was 9% compared to 3% in the intubation group. The fact that only 610 of 2165 screened infants were ultimately enrolled in the study leaves room for speculation of how this might have affected the results. For one thing, the very high rate of antenatal corticosteroids (94% in both groups) could have biased the results in favour of the CPAP group. Finally, randomized trials comparing different technologies assume that their application is operator-independent which may or may not be true (it's the driver, not the machine!). TMB
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