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Feasibility and Effect of Physiological-Based CPAP in Preterm Infants at Birth
Tessa Martherus1, Kristel L A M Kuypers1, Stefan Böhringer2
1Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands.
Insights
Physiological-based (PB)-CPAP in preterm infants shows feasibility, increasing heart rate and shortening ventilation time. However, achieving target oxygen saturation and adapting the protocol presented challenges.
Area of Science:
- Neonatal Medicine
- Respiratory Physiology
- Pediatric Critical Care
Background:
- Preterm infants often receive 5-8 cmH2O Continuous Positive Airway Pressure (CPAP).
- Animal studies suggest higher initial CPAP levels (12-15 cmH2O) followed by reduction (PB-CPAP) may enhance lung aeration without compromising cardiovascular function.
Purpose of the Study:
- To assess the feasibility of implementing a physiological-based CPAP (PB-CPAP) protocol in preterm infants at birth.
- To evaluate the effects of PB-CPAP compared to standard CPAP on physiological parameters and short-term outcomes.
Main Methods:
- A randomized trial involving preterm infants (24-30 weeks gestation) comparing PB-CPAP with standard 5-8 cmH2O CPAP for the initial 10 minutes post-birth.
- PB-CPAP involved starting at 15 cmH2O and gradually decreasing to 8 cmH2O upon infant stabilization (heart rate ≥100 bpm, SpO2 ≥85%, FiO2 ≤0.4, spontaneous breathing).
- Primary outcomes included feasibility and SpO2 within the first 5 minutes; secondary outcomes covered physiological parameters and neonatal outcomes.
Main Results:
- The study was halted early with 28 infants analyzed (PB-CPAP n=8, standard CPAP n=20) due to low recruitment and guideline changes.
- While SpO2 levels in the first 5 minutes were not significantly different, PB-CPAP infants showed higher heart rates (p=0.016) and reduced mask ventilation duration (p=0.020).
- Caregivers found the PB-CPAP protocol difficult to execute, and protocol deviations occurred in both groups, indicating challenges in tailoring CPAP levels.
Conclusions:
- Implementing PB-CPAP in preterm infants is feasible but presents practical challenges in protocol adherence and adjustment.
- PB-CPAP demonstrated potential benefits by increasing heart rate and shortening ventilation duration, possibly indicating improved lung aeration.
- Further research is needed to refine PB-CPAP protocols for easier clinical application and to confirm its long-term benefits.
Abstract:
Background: Preterm infants are commonly supported with 5-8 cmH2O CPAP. However, animal studies demonstrate that high initial CPAP levels (12-15 cmH2O) which are then reduced (termed physiological based (PB)-CPAP), improve lung aeration without adversely affecting cardiovascular function. We investigated the feasibility of PB-CPAP and the effect in preterm infants at birth. Methods: Preterm infants (24-30 weeks gestation) were randomized to PB-CPAP or 5-8 cmH2O CPAP for the first 10 min after birth. PB-CPAP consisted of 15 cmH2O CPAP that was decreased when infants were stabilized (heart rate ≥100 bpm, SpO2 ≥85%, FiO2 ≤ 0.4, spontaneous breathing) to 8 cmH2O with steps of ~2/3 cmH2O/min. Primary outcomes were feasibility and SpO2 in the first 5 min after birth. Secondary outcomes included physiological and breathing parameters and short-term neonatal outcomes. Planned enrollment was 42 infants. Results: The trial was stopped after enrolling 31 infants due to a low inclusion rate and recent changes in the local resuscitation guideline that conflict with the study protocol. Measurements were available for analysis in 28 infants (PB-CPAP n = 8, 5-8 cmH2O n = 20). Protocol deviations in the PB-CPAP group included one infant receiving 3 inflations with 15 cmH2O PEEP and two infants in which CPAP levels were decreased faster than described in the study protocol. In the 5-8 cmH2O CPAP group, three infants received 4, 10, and 12 cmH2O CPAP. During evaluations, caregivers indicated that the current PB-CPAP protocol was difficult to execute. The SpO2 in the first 5 min after birth was not different [61 (49-70) vs. 64 (47-74), p = 0.973]. However, infants receiving PB-CPAP achieved higher heart rates [121 (111-130) vs. 97 (82-119) bpm, p = 0.016] and duration of mask ventilation was shorter [0:42 (0:34-2:22) vs. 2:58 (1:36-6:03) min, p = 0.020]. Infants in the PB-CPAP group required 6:36 (5:49-11:03) min to stabilize, compared to 9:57 (6:58-15:06) min in the 5-8 cmH2O CPAP group (p = 0.256). There were no differences in short-term outcomes. Conclusion: Stabilization of preterm infants with PB-CPAP is feasible but tailoring CPAP appeared challenging. PB-CPAP did not lead to higher SpO2 but increased heart rate and shortened the duration of mask ventilation, which may reflect faster lung aeration.
