Background: Preterm infants ≤32 weeks' gestation are increasingly being managed on continuous positive airway pressure (CPAP), without prior intubation and surfactant therapy. Some infants treated in this way ultimately fail on CPAP and require intubation and ventilation. Objectives: To define the incidence, predictors and consequences of CPAP failure in preterm infants managed with CPAP from the outset. Methods: Preterm infants 25-32 weeks' gestation were included in the study if inborn and managed with CPAP as the initial respiratory support, with division into two gestation ranges and grouping according to whether they were successfully managed on CPAP (CPAP-S) or failed on CPAP and required intubation <72 h (CPAP-F). Predictors of CPAP failure were sought, and outcomes compared between the groups. Results: 297 infants received CPAP, of which 65 (22%) failed, with CPAP failure being more likely at lower gestational age. Most infants failing CPAP had moderate or severe respiratory distress syndrome radiologically. In multivariate analysis, CPAP failure was found to be predicted by the highest FiO2 in the first hours of life. CPAP-F infants had a prolonged need for respiratory support and oxygen therapy, and a higher risk of death or bronchopulmonary dysplasia at 25-28 weeks' gestation (CPAP-F 53% vs. CPAP-S 14%, relative risk 3.8, 95% CI 1.6, 9.3) and a substantially higher risk of pneumothorax at 29-32 weeks. Conclusion: CPAP failure in preterm infants usually occurs because of unremitting respiratory distress syndrome, is predicted by an FiO2 ≥0.3 in the first hours of life, and is associated with adverse outcomes.

1.
Jobe AH: Transition/adaptation in the delivery room and less RDS: ‘Don't just do something, stand there!'. J Pediatr 2005;147:284-286.
2.
Finer N: To intubate or not - that is the question: continuous positive airway pressure versus surfactant and extremely low birth weight infants. Arch Dis Child Fetal Neonatal Ed 2006;91:F392-F394.
3.
Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB: Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008;358:700-708.
4.
Finer NN, Carlo WA, Walsh MC, Rich W, Gantz MG, Laptook AR, Yoder BA, Faix RG, Das A, Poole WK, Donovan EF, Newman NS, Ambalavanan N, Frantz ID, III, Buchter S, Sanchez PJ, Kennedy KA, Laroia N, Poindexter BB, Cotten CM, Van Meurs KP, Duara S, Narendran V, Sood BG, O'Shea TM, Bell EF, Bhandari V, Watterberg KL, Higgins RD: Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010;362:1970-1979.
5.
Dunn MS, Kaempf J, de KA, de KR, Reilly M, Howard D, Ferrelli K, O'Conor J, Soll RF: Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011;128:e1069-e1076.
6.
Gallimore V: The Report of the Australian and New Zealand Neonatal Network, 2007. Sydney, Australian & New Zealand Neonatal Network, 2011.
7.
Ammari A, Suri M, Milisavljevic V, Sahni R, Bateman D, Sanocka U, Ruzal-Shapiro C, Wung JT, Polin RA: Variables associated with the early failure of nasal CPAP in very low birth weight infants. J Pediatr 2005;147:341-347.
8.
Aly H, Massaro AN, Patel K, El Mohandes AA: Is it safer to intubate premature infants in the delivery room? Pediatrics 2005;115:1660-1665.
9.
Fuchs H, Lindner W, Leiprecht A, Mendler MR, Hummler HD: Predictors of early nasal CPAP failure and effects of various intubation criteria on the rate of mechanical ventilation in preterm infants of <29 weeks gestational age. Arch Dis Child Fetal Neonatal Ed 2011;96:F343-F347.
10.
De Jaegere AP, van der Lee JH, Cante C, van Kaam AH: Early prediction of nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation. Acta Paediatr 2011;101:374-379.
11.
Pillai MS, Sankar MJ, Mani K, Agarwal R, Paul VK, Deorari AK: Clinical prediction score for nasal CPAP failure in pre-term VLBW neonates with early onset respiratory distress. J Trop Pediatr 2011;57:274-279.
12.
Kero PO, Makinen EO: Comparison between clinical and radiological classification of infants with the respiratory distress syndrome (RDS). Eur J Pediatr 1979;130:271-278.
13.
Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM: Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics 1988;82:527-532.
14.
Papile LA, Burstein J, Burstein R, Koffler H: Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978;92:529-534.
15.
Walsh MC, Kliegman RM, Fanaroff AA: Necrotizing enterocolitis: a practitioner's perspective. Pediatr Rev 1988;9:219-226.
16.
Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, Solimano A, Tin W: Long-term effects of caffeine therapy for apnea of prematurity. N Engl J Med 2007;357:1893-1902.
17.
Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, Hale EC, Newman NS, Schibler K, Carlo WA, Kennedy KA, Poindexter BB, Finer NN, Ehrenkranz RA, Duara S, Sanchez PJ, O'Shea TM, Goldberg RN, Van Meurs KP, Faix RG, Phelps DL, Frantz ID III, Watterberg KL, Saha S, Das A, Higgins RD: Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010;126:443-456.
18.
Gerber A, Dargaville PA; for the ANZNN: Early CPAP failure in preterm infants 25-32 weeks gestation is associated with increased neonatal morbidity. PAS abstract 2012.
19.
Cherif A, Hachani C, Khrouf N: Risk factors of the failure of surfactant treatment by transient intubation during nasal continuous positive airway pressure in preterm infants. Am J Perinatol 2008;25:647-652.
20.
Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK: Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N Engl J Med 1971;284:1333-1340.
21.
McCord FB, Curstedt T, Halliday HL, McClure G, Reid MM, Robertson B: Surfactant treatment and incidence of intraventricular haemorrhage in severe respiratory distress syndrome. Arch Dis Child 1988;63:10-16.
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