This document provides an overview of a seminar on CPAP in neonatal practice. It includes two case scenarios of premature infants with respiratory distress and then outlines what CPAP is, the history of its use, types of CPAP devices, how CPAP works, indications and contraindications for its use, essentials of providing CPAP including monitoring infants on CPAP and managing complications. Studies are summarized that show benefits of CPAP for preventing morbidity and mortality in premature infants as well as its use after extubation. Guidelines are provided on initiating, maintaining and weaning infants from CPAP support.

1. WELCOME TO THE SEMINAR
Dr. Ajara Khatun
Resident, year 1
Department of General Paediatrics
Dr. Sultana Jahan
Resident, year-4,
Department of Neonatology

2. Scenario-1
• B/o Anjana, Preterm (28wk), extremely low birth weight (900g)
admitted in NICU due to prematurity and low birth weight. On day-
3 baby developed repeated apnea, in between attack baby had
spontaneous respirations and reflex activities were good. During
attack baby was euglycemic, well- perfused, normothermic.

3. Scenario-2
• B/O Forida, 15 mins old admitted with prematurity (33 wks), low birth
weight (1550g) and respiratory distress soon after birth. Baby cried
immediately after birth and APGAR score was good. Mother had no
history of taking antenatal corticosteroids.
• On arrival baby was normothermic, euglycemic, reflex & activities were
good, but having respiratory distress in the form of tachypnea, nasal
flaring, chest retraction & grunting.

4. What will be the preferred mode of respiratory support ?

5. CPAP In Neonatal Practice

6. Outlines
• Definition
• History
• Types of CPAP
• Advantages and disadvantages
• Devices used for CPAP delivery
• How CPAP works and effects
• Indications
• contraindications
• Essentials of CPAP
• Care of new born on CPAP
• How to monitor while on CPAP?
• Complication
• Procedures of removal of CPAP
• CPAP failure

7. CPAP

8. Definition
• CPAP refers to the application of positive pressure to the airway of
a spontaneously breathing infant through out the respiratory cycle.

9. HISTORY
The first clinical use of CPAP was reported by Gregory et al in a landmark
report in 1971.
 After the initial enthusiasm, it gradually fell out of favor in 1980s because of
the advent of newer modes of ventilation.
 However, reports of significantly lower incidence of chronic lung disease
(CLD) from Columbia University unit, that used more CPAP as compared to
other North American Centers have led to resurgence of interest in CPAP over
the past 15 years.

10. Types of CPAP:

11. Advantages & disadvantages of different CPAP
Devices Advantages Disadvantages
Conventional ventilator derived
CPAP
•No need of a separate
equipments
•Can be easily switched over to
MV if CPAP fails
•Expensive
•Presence of high leak
•Difficult to know set flow is
sufficient or not
Stand-alone CPAP machines •Economical
•Useful for small hospitals
•Can have bubble CPAP option
•Most of them do not have proper
blenders and /or pressure
manometer
Bubble CPAP •Simple and inexpensive
•Oscillations produced by
continuous bubbling contribute
gas exchange
•Flow has to be altered to ensure
proper bubbling
•It is difficult to detect high flow
which lead to over-distension of
the lung.

12. Devices used for CPAP delivery
• Various devices used for CPAP delivery include:
1. Nasal prongs (single/double or binasal)
2. Long (or) nasopharyngeal prongs
3. Nasal cannula
4. Nasal masks.
• Face mask, endotracheal, and head box are no longer used for CPAP delivery in
neonates. Endotracheal CPAP is not recommended because it has been found to
increase the work of breathing (infant has to breathe ‘through a straw’).

13. CPAP delivery systems
1
2
3
4
Fig:
1. Nasal mask
2. Nasal prong
3. Long
nasopharyngeal
prong
4. ET tube

14. Delivery systems Advantages Disadvantages
Nasal prongs Simple
Lower resistance leads to greater
transmission of pressure
Difficult to fix
Risk of trauma of nasal septum
Nasopharyngeal prongs Easy availability
Economical
More secure fixation
More easily block by secretions
Likely to get kinked.
Nasal cannulae Ease of application Unreliable pressure delivery
Need high flow to generate pressure
Large leaks around cannula.
Nasal mask Minimal nasal trauma Difficulty in obtaining an adequate
seal
Advantages & disadvantages of common delivery systems

15. Parts of CPAP:

16. CPAP machines in our NICU
Fig: oxygen concentrator CPAP Fig: BUBBLE CPAP

17. How CPAP works?

19. Indications for CPAP
• CPAP is very useful in preterm (<35 weeks) infants with respiratory distress of
any etiology.
 RDS
 Apnea of prematurity
 Post-extubation in VLBW infants
 Delayed adaptation / TTN
 Pneumonia
 Meconium aspiration syndrome

20. Time of application
 Early: Within 2 hour of distress
 Late: after FiO2 requirement > 0.4

21. When to initiate CPAP?
Early CPAP:
 All preterm infants (<35 weeks’ gestation) with any sign of respiratory
distress (tachypnea / chest in-drawing / grunting) should be started
immediately on CPAP.
 Once atelectasis and collapse have occurred, CPAP might not help much.

22. Prophylactic CPAP:
Some have advocated the use of prophylactic CPAP (before the onset of
respiratory distress) in preterm VLBW infants as majority of them would
eventually develop respiratory distress.

23. Prophylacticnasal continuous positive airwaypressure for preventing morbidityand mortalityin very preterm
infants
Cochrane Systematic Review - Intervention Version published: 14 June 2016
Seven studies involving 3123 infants.
In the four studies (765 babies) comparing CPAP with supportive care, CPAP
resulted in fewer infants requiring further breathing assistance.
In the three studies (2354 babies) that compared CPAP with assisted
ventilation with or without surfactant, CPAP resulted in a small but clinically
important reduction in BPD and the combined outcome of BPD and mortality.
There was a reduction in the need for mechanical ventilation and the use of
surfactant in the CPAP group.
Subramaniam P, Ho JJ, Davis PG

24. Use of nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway
pressure (NCPAP) after extubation reduces the incidence of extubation failure within 48 hours to
seven days. Studies using synchronized NIPPV and delivering NIPPV to infants by a ventilator observed
benefits more consistently. Investigators noted no overall reduction in chronic lung disease among infants
randomized to NIPPV and reported a reassuring absence of the gastrointestinal side effects that had been
reported in previous case series.
Cochrane Database of Systematic Reviews 2017, Issue 2.
Art. No.: CD003212

26. • Results: In all, 47 of 57 (82.5%) neonates from BCPAP group and 36 of 57
(63.2%) neonates from the VCPAP group completed CPAP successfully
(p¼0.03). Neonates who failed CPAP had higher Silverman–Anderson score
(p<0.01), lower arterial to alveolar oxygenation ratio (p<0.05) and needed
surfactant more frequently (p<0.01).
• Conclusion: BCPAP has higher success rate than VCPAP for managing
preterm neonates with early onset respiratory distress, with comparable safety.
Bubble CPAP versus Ventilator CPAP in Preterm Neonates with Early Onset Respiratory Distress—
A Randomized Controlled Trial
Amit Tagare, Sandeep Kadam, Umesh Vaidya, Anand Pandit and Sanjay Patole
JOURNAL OF TROPICAL PEDIATRICS, VOL. 59, NO. 2, 2013

27. CPAP is considered to be adequate if a baby on CPAP is
 Comfortable
 Has minimal or no chest retractions
 Has normal CFT, blood pressure
 SpO2 is between 90-95%
 Optimum Chest expansion: 7-8 ICS above diaphragm
 Blood gas:
PaO2 is 50 to 80 mmHg, PCO2 is 40 to 60 mmHg
pH is 7.35 to 7.45

28. Contraindications to CPAP
1. Progressive respiratory failure with PCO2> 60 mmHg and/or inabitity to
maintain oxygenation (PO2< 50 mmHg)
2. Congenital malformations of the airway
- Choanal atresia
- Cleft palate
- Tracheo-esophageal fistula
- Congenital diaphragmatic hernia
3. Conditions with imminant ventilatory support
- Severe cardio-respiratory compromise (Hypotension)
-Poor respiratory drive that is not improved by CPAP

29. Essentials of CPAP
Preparing the circuit, the bubble chamber and the machine
Fixing the cap
Securing the nasal prongs or nasal mask
Connecting the circuit
Insertion of orogastric tube
Setting of pressure, FiO2, and flow

30. Setting and Role of Pressure, FiO2 and flow
Pressure:
 Ideal range of pressure is from 4 cm to 8 cm of water
 Increase or decrease pressure to minimize chest retractions, maintain 6 to 8
posterior rib spaces in CXR and to maintain PaO2 > 50mm Hg
FiO2:
Ideal FiO2 is from 21% to 60%
It is adjusted to maintain SPO2 between 90% to 95%
Always increase pressure
before FiO2 for better
oxygenation
Ref: Work shop on CPAP, AIIMS, New Delhi,
2017

31. Flow:
Range of flow is from 5 to 8 L /min
Flow changes are made only for delivering adequate pressure
Too high flow results in wastage of gases, turbulence and inadvertent high
pressure

32. Application of CPAP therapy in the three common neonatal conditions
Indications
RDS Apnea of prematurity Post extubation
How to initiate CPAP?
Pressure
Fio2
• Start at 6-7 cm of H2O
• 0.5 (titrate based on
SPO2)
• 4-5 cm of H2O
• 0.21- 0.4
• 4-5 cm of H2O
• 0.05 – 0.1above the
pre-extubation FiO2
What to do if there is
no improvement?
Pressure
FIO2
• Increase in steps of 1-2
cm H2O to reach a
maximum of 7-8 cm
H2O
• Increase in steps of
0.05 up to a maximum
of 0.8
• Increase up to 5 cm H2O.
• FiO2 increase does not
help much
• Increase in steps of 1-2
cm H2O to reach a
maximum of 7-8 cm
H2O
• Increase in steps of
0.05 up to a maximum
of 0.8

33. Weaning from CPAP
When to wean ?
 When baby fulfills the criteria of having “Optimum CPAP” attempts should be taken to wean
from CPAP
 Apnea free for > 24 hours
How to wean ?
 If FiO2 > 50% and CPAP pressure > 5 cmH2O: decrease FiO2 to 50% then decrease
pressure
 Once FiO2 50% wean it a level < 30% before reducing pressure from 5 to 4 cmH2O
 At CPAP pressure of 4 cmH2O and with a FiO2 < 30% with normal SpO2 and minimal
retractions, CPAP may be removed.

34. J Perinatol.2017 Jun;37(6):662-667
Sudden versus gradual pressure wean from Nasal CPAP in preterm infants: a
randomized controlled trial.
Amatya S, Macomber M, Bhutada A, Rastogi D, Rastogi S
OBJECTIVE: In preterm infants, nasal continuous positive airway pressure (NCPAP) is widely used for treatment of
respiratory distress syndrome. However, the strategies for successfully weaning infants off NCPAP are still not well defined
and there remains considerable variation between the methods. The objective of this study is to determine whether gradual
weaning of NCPAP pressure is more successful than sudden weaning off NCPAP to room air.
Conclusions:
Gradual weaning method was more successful as compared to sudden
weaning method in the initial trial off NCPAP. There was no difference in the
PMA, weight at the time of successful wean.

35. World J Pediatr.2015 Feb;11(1):7-13.
Weaning of nasal CPAP in preterm infants: who, when and how? a systematic review of
the literature.
Amatya S, Rastogi D, Bhutada A, Rastogi S.
BACKGROUND: There is increased use of early nasal continuous positive airway pressure (NCPAP) to manage respiratory distress in
preterm infants but optimal methods and factors associated with successful wean are not well defined. A systematic review was
performed to define the corrected gestational age (CGA), weight to wean NCPAP and the methods associated with successful weaning
of the NCPAP among preterm infants, along with factors affecting it.
RESULTS :Seven studies met the search criteria. The successful wean was at 32 to 33 weeks CGA
and at 1600 g. Three different methods were used for weaning were sudden, gradual pressure wean and
gradual graded time off wean. Criteria for readiness, success and failure to wean were defined. Factors
affecting successful weaning were intubation, anemia, infection and gastro-esophageal reflux.
CONCLUSIONS :The successful wean was at 32 to 33 weeks CGA and 1600 g. Criteria for
readiness, success and failure to wean are well defined. Sudden weaning may be associated with a
shorter weaning time. Future trials are needed comparing weaning methods using defined criteria for
readiness and success of NCPAP wean and stratify the results by gestational age and birth weight.

36. Care of Infant on CPAP:
• The nasal prongs/ nasal mask can be secured by putting on an appropriate
sized hat
• Nasal prongs/ nasal mask must be properly placed to prevent air leak
• Gentle nasal suctioning is important to maintain clear airways
• Frequent decompression of the infant’s stomach with an oro-gastric tube is
necessary

37. Contd.
• Regular but gentle nasal suction to clear the mucus 4 hourly or as and when
required
• Clean the nasal cannula and check its patency once per shift
• Change the infant’s position regularly every 2-4 hours and check the skin
condition frequently for redness and sores.

38. Monitoring of adequacy and complications of CPAP
 Vitals: Heart rate, temperature, respiratory rate, blood pressure and SpO2
 Circulation: CRT, Blood pressure and urine output
 Scoring of respiratory distress: Silverman score or Downe’s score
 Abdominal distension: bowel sounds and gastric aspirates to prevent CPAP
belly
 Neurological assessment: Tone, activity and responsiveness
 CXR
 Blood gas

39. • Adjust settings to maintain gas
humidification at or close to 100%
• Set the humidifier temp to 36.5-37.5o C
Humidification

40. Adverse effects of poor humidification
 Drying of the mucosa and secretions in the airway
 Damage to the immature mucociliary function
 Accumulation of secretions in the lower airways and predisposition to
pneumonia or recurrent collapse
 Dry secretion & thick mucus narrow the airway and lead to increased work of
breathing
 Exposure to dry & cold gases leads to bronchoconstrictions

41. Complications associated with CPAP
 Nasal irritation, damage to the septal mucosa, or skin damage and necrosis from
the fixing devices.
 Nasal obstruction
- Remove secretions and check for proper positioning of
the prongs
 Infection
 Gastric distension
 CPAP belly syndrome
 IVH
 Pneumothorax
 Hypoperfusion

42. • Septal injury is preventable
• Damage to the septum arises when poorly fitted or mobile prongs/ nasal
mask cause pressure and/or friction
Preventing Complications: Nasal Septal Injury

43. Trauma due to Nasal Mask

44. Figure

46. Comparison of Nasal Mask Versus Nasal Prongs for Delivering
Nasal Continuous Positive Airway Pressure in Preterm Infants
with Respiratory Distress Syndrome (unpublished)
Thesis work: Dr Bipin Karki
Department of Neonatology, BSMMU Shahbagh, Dhaka, Bangladesh
October-2017
Objective of the study: To compare the efficacy of nasal mask vs nasal
prongs in delivering nasal continuous positive airway pressure in preterm
infants with respiratory distress syndrome.
Conclusion: NCPAP with mask interface is equally
effective as NCPAP with prongs interface. Incidence of
stage II nasal trauma was significantly lower in mask
group than in the prongs group.

48. Eur J Pediatr. 2017 Mar;176(3):379-386.
Nasal masks or binasal prongs for delivering continuous positive airway
pressure in preterm neonates-a randomised trial.
Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul VK, Deorari AK
The objective of this study was to compare the efficacy and safety of continuous positive airway pressure
(CPAP) delivered using nasal masks with binasal prongs. We randomly allocated 72 neonates between
26 and 32 weeks gestation to receive bubble CPAP by either nasal mask (n = 37) or short binasal prongs
(n = 35). Incidence of severe nasal trauma was lower with the use of nasal masks (0 vs. 31%; p < .001).
CONCLUSIONS:
Nasal masks appear to be as efficacious as binasal prongs in providing CPAP. Masks
are associated with lower risk of severe nasal trauma.

49. Neonatology 2016;109:258-264
Binasal Prong versus Nasal Mask for Applying CPAP to Preterm Infants: A
Randomized Controlled Trial
Say B. Kanmaz Kutman H.G. Oguz S.S. Oncel M.Y Arayici S. Canpolat F.E. Uras N. Karahan S.
Objective: We aimed to determine whether NCPAP applied with binasal prongs compared to
that with a nasal mask (NM) reduces the rate of moderate/severe bronchopulmonary dysplasia
(BPD) in preterm infants.
Conclusions:
The NM was successfully used for delivering NCPAP in preterm infants, and no
NCPAP failure was observed within the first 24 h. These data show that applying
NCPAP by NM yielded a shorter duration of NCPAP and statistically reduced the rates
of moderate and severe BPD.

50. To prevent gastric distention:
• Assess the infant’s abdomen
regularly
• Pass an oro-gastric tube to aspirate
excess air before feeds
• An 5 Fr oro-gastric tube should be
left indwelling to allow for continuous
air removal
CPAP belly
Gaseous distension

51. AJRAm J Roentgenol. 1992 Jan;158(1):125-7.
Benign gaseous distension of the bowel in premature
infants treated with nasal continuous airway pressure: a study of contributing factors.
Jaile JC, Levin T, Wung JT, Abramson SJ, Ruzal-Shapir C, Berdon WE.
Associated with the increased use of nasal CPAP has been the development of marked bowel distension (CPAP belly
syndrome), which occurs as the infant's respiratory status improves and the baby becomes more vigorous. To identify
contributing factors, compared 5 premature infants treated with nasal CPAP with 29 premature
infants not treated with nasal CPAP. Infants were followed up for development of distension, defined clinically as bulging flanks,
increased abdominal girth, and visibly dilated intestinal loops. We evaluated birth weight, weight at time of distension, method
of feeding (oral, orogastric tube), and treatment with nasal CPAP and correlated these factors with radiologic findings.
Of the infants who received nasal CPAP therapy, gaseous bowel distension developed in 83% (10/12) of infants weighing less
than 1000 g, but in only 14% (2/14) of those weighing at least 1000 g. Only 10% (3/29)
of infants not treated with nasal CPAP had distension, and all three weighed less than 1000 g. Presence of sepsis and method
of feeding did not correlate with occurrence of distension. Neither necrotizing enterocolitis nor bowel obstruction developed in
any of the patients with a diagnosis of CPAP belly syndrome.
The study shows that nasal CPAP, aerophagia, and immaturity of bowel motility in very
small infants were the major contributors to the development
of benign gaseous bowel distension.

52. • The infant on CPAP may be
positioned supine, prone, or side
lying ( repositioning for at least every
3to 6 hours ).
• When positioning supine or side lying
support airway alignment with a neck
roll
Positioning While on CPAP

53. Pass an orogastric tube
Keep the proximal end of tube open
 If the infant is being fed while on CPAP, close the tube for half an
hour after giving feeds
Keep it open for the next 90 minutes (if fed 2hourly)
Feeding While on CPAP

54.  The baby requires frequent change in posture, oral and nasal suction
and occasionally saline nebulization for effective removal of secretion
should be done prior to, and after removal of CPAP.
 For the 12 to 24 hours after removal of CPAP, careful monitoring is
required for evidence of tachypnea, worsening retractions, apneas and
bradycardia.
After removal from CPAP..

55. Worsening respiratory distress as indicated by Silverman or Downe’s scoring
Apnea > 3 episodes/hr or 1 episode needing bag mask ventilation
ABG:
• PCO2 >60 mm Hg)
• PO2 <50 mm Hg)
• FiO2 ≥ 0.6
• Ph <7.25
Failure of CPAP

56. Causes of CPAP failure
• Delay in initiating CPAP
• Intracranial hemorrhage
• Progressive metabolic acidosis
• Pulmonary edema
• Improper fixation of CPAP device and frequent dislodgement
• Excessive secretions obstructing the airways or nasal prongs

57. Results: Of the 189 infants in the MC, 50% failed CPAP. Compared to CSG, infants in the CFG had lower
antenatal steroid exposure, birth weight, higher radiographic severe respiratory distress syndrome (RDS)
and fraction of inspired oxygen (FiO2). A forward stepwise logistic regression modeling in both MC and VC
showed that FiO2 >0.3 and radiographic severe RDS predicted CPAP failure.
Conclusion: FiO2 >0.3 within two HOL and radiographic severe RDS predicts CPAP failure in preterm
infants.

58. Journal ofTropical Pediatrics, Volume 57, Issue 4, 1August 2011, Pages 274–279,
Clinical Prediction Score for Nasal CPAP Failure in Pre-term VLBW Neonates with Early Onset
Respiratory Distress
Mrinal S. Pillai Mari J. Sankar Kalaivani Mani Ramesh Agarwal Vinod K. PaulAshok K. Deorari
Abstract:62 pre-term very low birth weight neonates initiated on nasal continuous positive airway
pressure (CPAP) for respiratory distress in the first 24 h of life to devise a clinical score for predicting its
failure. CPAP was administered using short binasal prongs with conventional ventilators. On multivariate
analysis, we found three variables—gestation <28 weeks [adjusted odds ratio (OR) 6.5; 95% confidence
interval (CI) 1.5–28.3], pre-term premature rupture of membranes [adjusted OR 5.3; CI 1.2–24.5], and
product of CPAP pressure and fraction of inspired oxygen ≥1.28 at initiation to maintain saturation
between 88% and 93% [adjusted OR 3.9; CI 1.0–15.5] to be independently predictive of failure. A
prediction model was devised using weighted scores of these three variables and lack of exposure to
antenatal steroids. The clinical scoring system thus developed had 75% sensitivity and 70% specificity
for prediction of CPAP failure (area under curve: 0.83; 95% CI 0.71–0.94).
Conclusion:
A simple clinical score comprising four variables namely, gestational age <28 weeks, PPROM,
lack of exposure to ANS, and product of CPAP pressure and FiO2 ≥1.28 would predict failure of
nasal CPAP in pre-term VLBW infants with reasonable accuracy.

59. Pediatrics July 2016, VOLUME 138 / ISSUE 1
Incidence and Outcome of CPAP Failure in Preterm Infants
Peter A. Dargaville, Angela Gerber, Stefan Johansson, Antonio G. De Paoli, C. Omar F. Kamlin, Francesca
Orsini, Peter G. Davis, for the Australian and New Zealand Neonatal Network
RESULTS: Within the cohort of 19 103 infants, 11 684 were initially managed on CPAP. Failure of CPAP
occurred in 863 (43%) of 1989 infants commencing on CPAP at 25–28 weeks’ gestation and 2061
(21%) of 9695 at 29–32 weeks. CPAP failure was associated with a substantially higher rate of
pneumothorax, and a heightened risk of death, bronchopulmonary dysplasia (BPD) and other
morbidities compared with those managed successfully on CPAP. The incidence of death or BPD was
also increased: (25–28 weeks: 39% vs 20%, AOR 2.30, 99% confidence interval 1.71–3.10; 29–32
weeks: 12% vs 3.1%, AOR 3.62 [2.76–4.74]). The CPAP failure group had longer durations of
respiratory support and hospitalization.
CONCLUSIONS:
CPAP failure in preterm infants is associated with increased risk of mortality and major
morbidities, including BPD. Strategies to promote successful CPAP application should be pursued
vigorously.

60.  If the infant develops frequent apnea and bradycardia episodes, tachypnea
or retractions, then CPAP is reintroduced
Indications for reintroducing CPAP

61. Am J Perinatol. 2011Apr;28(4):315-20.
Nasal colonization among premature infants treated with nasal continuous
positive airway pressure.
Aly H, Hammad TA, Ozen M, Sandhu I, Taylor C, Olaode A, Mohamed M, Keiser J.
o Nasal colonization with gram-negative bacilli was increased with the use of CPAP in all birth-
weight categories ( P < 0.05) and with vaginal delivery in infants weighing < 1000 g and 1500 to
2499 g ( P = 0.04 and P = 0.02, respectively). Nasal colonization with any potential pathogen
increased with the use of CPAP in all birth-weight categories ( P < 0.001), with the presence of
chorioamnionitis in infants < 1000 g ( P = 0.055) and at younger gestational age in infants 1000
to 1499 g ( P = 0.0026). Caucasian infants 1500 to 2499 g had less colonization than infants of
other races ( P = 0.01).
o Nasal CPAP is associated with increased colonization with gram-negative bacilli.

62. Indian J Pediatr. 2012 Feb;79(2):218-23.
Neurodevelopmental outcomes of extremely low birth weight infants ventilated
with continuous positive airway pressure vs. mechanical ventilation.
Thomas CW, Meinzen-Derr J, Hoath SB, Narendran V.
OBJECTIVE:
To compare continuous positive airway pressure (CPAP) vs. traditional mechanical ventilation (MV) at
24 h of age as predictors of neurodevelopmental (ND) outcomes in extremely low birth weight (ELBW)
infants at 18-22 months corrected gestational age (CGA).
RESULTS:
Ventilatory groups were similar in gender, rates of preterm prolonged rupture of membranes, antepartum
hemorrhage, use of antenatal antibiotics, steroids, and tocolytics. Infants receiving CPAP weighed more,
were older, were more likely to be non-Caucasian and from a singleton pregnancy. Infants receiving
CPAP had better BSID-II scores (18-22 months of corrected age), and lower rates of BPD and
death.
CONCLUSIONS:
After adjusting for acuity differences, ventilatory strategy at 24 h of age independently predicts long-term
neurodevelopmental outcome in ELBW infants.

63. J Perinatol. 2016 May;36 Suppl 1:S21-8.
Efficacy and safety of CPAP in low- and middle-income countries.
Thukral A, Sankar MJ, Chandrasekaran A, Agarwal R, Paul VK.
o Pooled analysis of four observational studies showed 66% reduction in in-hospital mortality
following CPAP in preterm neonates (odds ratio 0.34, 95% confidence interval (CI) 0.14 to 0.82). One
study reported 50% reduction in the need for mechanical ventilation following the introduction of
bubble CPAP (relative risk 0.5, 95% CI 0.37 to 0.66).
o The proportion of neonates who failed CPAP and required mechanical ventilation varied from 20 to
40% (eight studies).
o Available evidence suggests that CPAP is a safe and effective mode of therapy in preterm neonates
with respiratory distress in LMICs. It reduces the in-hospital mortality and the need for ventilation
thereby minimizing the need for up-transfer to a referral hospital.

64.  Nasal CPAP is an effective, safer and preferred mode of first line therapy in
the management of respiratory distress in preterm neonates.
 Early CPAP in preterm infants with respiratory distress also reduces the need
for surfactant therapy.
Take Home message