Early Nasal Continuous Positive Airway Pressure To Minimize The Need for Endotracheal Intubation and Ventilation

Abstract

After completing this article, readers should be able to: 1. Describe the mechanism by which early nasal continuous positive airway pressure (nCPAP) may reduce bronchopulmonary dysplasia (BPD). 2. List the limited evidence used to confirm the reduction in BPD. 3. List the limited evidence on which to base patient selection for early nCPAP. 4. Explain the uncertainty regarding whether to treat with surfactant replacement. When Northway and associates (1) initially described BPD in 1967, little was known about the injurious effects of ventilation and oxygen. Today, despite the numerous pharmacologic and technical advances in neonatal lung care, BPD remains a cause of serious morbidity in surviving preterm infants. This “new BPD” differs from that originally described by Northway in that it affects predominantly infants born between 24 and 28 weeks’ gestation who have birthweights of less than 1,000 g, many of whom have received antenatal glucocorticoids, minimal “gentle ventilation,” and exogenous surfactant therapy. (2) A variety of factors, including surfactant deficiency, volutrauma, oxygen exposure, antenatal exposure to proinflammatory cytokines, postnatal infection, patent ductus arteriosus, and inadequate postnatal nutrition, are believed to play roles in the pathogenesis of neonatal BPD. The single greatest predictor for BPD appears to be the initiation of mechanical ventilation in the very low-birthweight infant. (3)(4)(5) The introduction of more complex ventilatory strategies, such as high-frequency oscillatory ventilation (HFOV), (6) patient trigger, (7) and volume techniques have not been associated with a reduction in the incidence of BPD in extremely preterm babies. Long-term animal studies demonstrate that HFOV reduces the severity of lung injury but does not prevent the arrest in alveolarization and vascular development that underlies new BPD. (8)(9)(10) This failure may be due to the fact that all respiratory support strategies that involve endotracheal intubation for any length of …