From the Guidelines
This 1-week-old premature infant born at 29 weeks gestation should continue to receive nasal continuous positive airway pressure (CPAP) as the initial respiratory support, with selective surfactant administration as needed, as this approach has been shown to result in lower rates of bronchopulmonary dysplasia/death compared to routine intubation with prophylactic or early surfactant administration 1. The baby is currently tolerating enteral feeds via orogastric tube, which is encouraging for her gestational age, and her weight remains appropriate, suggesting adequate nutrition. Key aspects of her care include:
- Continued monitoring in the NICU with gradual advancement of feeds as tolerated
- Ongoing respiratory support with weaning as appropriate
- Regular assessment of growth parameters
- Developmental care and kangaroo care (skin-to-skin contact with parents) to promote optimal neurodevelopment
- Close monitoring for common complications such as apnea of prematurity, feeding intolerance, and infections, which are prevalent in premature infants at 29 weeks gestation. The current use of nasal CPAP, as recommended by recent multicenter randomized controlled trials 1, is a suitable approach for this patient, given her clinical presentation and the potential benefits of reduced bronchopulmonary dysplasia/death.
From the Research
Patient Evaluation
The patient is a 1-week-old girl born at 29 weeks gestation via spontaneous vaginal delivery due to preterm labor. She has been tolerating enteral feeds via an orogastric tube and her weight remains appropriate. Vital signs are normal, and examination shows a sleeping, nondysmorphic infant with a nasal continuous positive airway pressure (CPAP) mask in place.
Use of CPAP in Preterm Infants
- CPAP is a common treatment for respiratory distress syndrome in preterm infants, as it helps to keep the airways open and improve oxygenation 2, 3, 4.
- Studies have shown that prophylactic or very early initiation of CPAP may reduce the need for intubation and mechanical ventilation, and prevent bronchopulmonary dysplasia (BPD) in preterm infants 2.
- The use of CPAP in preterm infants has been associated with lower rates of failed treatment, decreased incidence of chronic lung disease, and lower overall mortality, especially in infants with birth weight above 1500 grams 4.
Comparison of CPAP to Mechanical Ventilation
- Prophylactic or very early CPAP compared to mechanical ventilation may reduce the incidence of BPD, the combined outcome of death and BPD, and mechanical ventilation 2.
- There is probably no difference in neurodevelopmental impairment at 18 to 22 months of age between preterm infants treated with CPAP and those treated with mechanical ventilation 2.
- The INSURE strategy (INtubate-SURfactant administration and Extubate to nasal CPAP) has been shown to be effective in reducing the need for mechanical ventilation and improving outcomes in preterm infants with respiratory distress syndrome 5, 6, 3.
Surfactant Therapy
- Surfactant is essential in the treatment of respiratory distress syndrome and has generally been reserved for infants on mechanical ventilation 6, 3.
- However, with the development of INSURE, surfactant therapy can be given during CPAP treatment, further reducing the need for mechanical ventilation 5, 6, 3.
- A new hydrophilic surfactant preparation has been developed, which may enable the introduction of surfactant therapy without the need for tracheal intubation 6.