Early Continuous Positive Airway Pressure Research Articles

Nasal Intermittent Positive-Pressure Ventilation vs Nasal Continuous Positive Airway Pressure for Preterm Infants With Respiratory Distress Syndrome

To determine among preterm infants with respiratory distress syndrome whether the use of early nasal intermittent positive-pressure ventilation (NIPPV) vs nasal continuous positive airway pressure (NCPAP) decreases the need for invasive ventilation within the first 72 hours of life. MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and clinicaltrials.gov were searched, as well as abstracts from meetings of the Pediatric Academic Societies. Randomized controlled trials involving infants with respiratory distress syndrome who received NIPPV vs NCPAP. Data were extracted on the use of NIPPV vs NCPAP. Also extracted were data on the need for invasive ventilation within the first 72 hours of life and the incidences of bronchopulmonary dysplasia, pneumothorax, necrotizing enterocolitis, and intraventricular hemorrhage, as well as the time to full feeds and the duration of hospital stay. Three trials were included (n = 360). A significant decrease in the need for invasive ventilation was found in the NIPPV group (risk ratio, 0.60; 95% CI, 0.43-0.83). No difference between groups was found in the incidence of bronchopulmonary dysplasia (risk ratio, 0.56; 95% CI, 0.09-3.49). No differences in the other outcomes were observed between the 2 groups. Among preterm infants with respiratory distress syndrome, NIPPV decreases the need for invasive ventilation within the first 72 hours of life compared with NCPAP. Trials are needed to assess whether NIPPV minimizes the occurrence of bronchopulmonary dysplasia and other comorbidities.

RDS – CPAP or surfactant or both

There is mounting evidence that early continuous positive airway pressure (CPAP) from birth is feasible and safe even in very preterm infants. However, many infants will develop respiratory distress syndrome (RDS) and require surfactant treatment. Combining a non-invasive ventilation approach with a strategy for surfactant administration is important, but questions remain about the optimal timing, mode of delivery and the value of predictive tests for surfactant deficiency. Early CPAP in very preterm infants is as safe as routine intubation in the delivery room. However, a strategy for surfactant administration should be part of a non-invasive ventilation approach for those infants at risk of developing significant RDS.

Randomized Trial of Early Bubble Continuous Positive Airway Pressure for Very Low Birth Weight Infants

To determine whether very low birth weight infants (VLBWIs), initially supported with continuous positive airway pressure (CPAP) and then selectively treated with the INSURE (intubation, surfactant, and extubation to CPAP; CPAP/INSURE) protocol, need less mechanical ventilation than those supported with supplemental oxygen, surfactant, and mechanical ventilation if required (Oxygen/mechanical ventilation [MV]). In a multicenter randomized controlled trial, spontaneously breathing VLBWIs weighing 800-1500 g were allocated to receive either therapy. In the CPAP/INSURE group, if respiratory distress syndrome (RDS) did not occur, CPAP was discontinued after 3-6 hours. If RDS developed and the fraction of inspired oxygen (FiO(2)) was >0.35, the INSURE protocol was indicated. Failure criteria included FiO(2) >0.60, severe apnea or respiratory acidosis, and receipt of more than 2 doses of surfactant. In the Oxygen/MV group, in the presence of RDS, supplemental oxygen without CPAP was given, and if FiO(2) was >0.35, surfactant and mechanical ventilation were provided. A total of 256 patients were randomized to either the CPAP/INSURE group (n = 131) or the Oxygen/MV group (n = 125). The need for mechanical ventilation was lower in the CPAP/INSURE group (29.8% vs 50.4%; P = .001), as was the use of surfactant (27.5% vs 46.4%; P = .002). There were no differences in death, pneumothorax, bronchopulmonary dysplasia, and other complications of prematurity between the 2 groups. CPAP and early selective INSURE reduced the need for mechanical ventilation and surfactant in VLBWIs without increasing morbidity and death. These results may be particularly relevant for resource-limited regions.

Atelectasis and perioperative pulmonary complications in high-risk patients

This review evaluates the link between perioperative lung atelectasis and postoperative pulmonary complications (PPCs) and how appropriate ventilatory strategies could mitigate this problem. Atelectasis may contribute to serious PPCs including respiratory failure and pneumonia. Ventilator settings during anesthesia, especially with higher tidal volumes (V(T)) (>10 ml/kg), high plateau pressures (>30 cmH(2)O) and without positive end expiratory pressure (PEEP), are associated with lung injury even in healthy, but partially collapsed, lungs. These injurious settings may cause inflammation which is related to repetitive tidal recruitment and alveolar overdistension. Such ventilator-induced lung injury can be attenuated by using low V(T) and plateau pressures at sufficient PEEP, ideally after actively recruiting the lungs. The use of continuous positive airway pressure and 'lower' FiO(2) during anesthetic induction, intraoperative use of lower FiO(2), low V(T), lung recruitment and PEEP ('protective ventilatory strategy') in conjunction with postoperative early mobilization, breathing exercises and continuous positive airway pressure may help in maintaining lung aeration, thereby decreasing hypoxemia and risk of postoperative pneumonia. Evidence is accumulating suggesting that the incidence of postoperative pulmonary complication could be markedly reduced if an 'open lung' philosophy was adopted for the perioperative care. A goal-directed ventilatory approach keeping an 'open lung' condition during the perioperative period may reduce the incidence of PPCs.

Early prediction of nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation

To predict early nasal continuous positive airway pressure failure within the first 2 h after birth in preterm infants. Patient and respiratory support variables significantly associated with continuous positive airway pressure failure in the first 72 h after birth were identified in a cohort of preterm infants <30 weeks gestation. Using multivariable logistic regression analysis, risk estimates for early nasal continuous positive airway pressure failure were calculated. From 182 infants included, 62(34%) failed early nasal continuous positive airway pressure. Birth weight ≤800 g, male gender and a fraction of inspired oxygen >0.25 at 1 and 2 h of age were significantly associated with early nasal continuous positive airway pressure failure. Combining these variables in a logistic regression model provided a minimal risk estimate for failure of 0.04[0.01-0.23] (female >800 g, FiO(2) ≤ 0.25 at 1, and 2 h) and maximal estimate of 0.92[0.44-0.99] (male ≤800 g, FiO(2) > 0.25 at 1 and 2 h). Combining gender, birth weight and the fraction of inspired oxygen at 1 and 2 h of age allows for a better and more individualized prediction of early nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation.

Positive effects of early continuous positive airway pressure on pulmonary function in extremely premature infants: results of a subgroup analysis of the COIN trial

Positive effects of early continuous positive airway pressure on pulmonary function in extremely premature infants: results of a subgroup analysis of the COIN trial

Impact of Changes in Perinatal Care on Neonatal Respiratory Outcome and Survival of Preterm Newborns: An Overview of 15 Years

Survival and outcomes for preterm infants with respiratory distress syndrome (RDS) have improved over the past 30 years. We conducted a study to assess the changes in perinatal care and delivery room management and their impact on respiratory outcome of very low birth weight newborns, over the last 15 years. A comparison between two epochs was performed, the periods before and after 2005, when early nasal continuous positive airway pressure (NCPAP) and Intubation-SURfactant-Extubation (INSURE) were introduced in our center. Three hundred ninety-five clinical records were assessed, 198 (50.1%) females, gestational age 29.1 weeks (22–36), and birth weight 1130 g (360–1498). RDS was diagnosed in 247 (62.5%) newborns and exogenous surfactant was administered to 217 (54.9%). Thirty-three (8.4%) developed bronchopulmonary dysplasia (BPD), and 92 (23%) were deceased. With the introduction of early NCPAP and INSURE, there was a decrease on the endotracheal intubation need and invasive ventilation (P < 0.0001), oxygen therapy (P = 0.002), and mortality (P < 0.0001). The multivariate model revealed a nonsignificant reduction in BPD between the two epochs (OR = 0.86; 95% CI 0.074–9.95; P = 0.9). The changes in perinatal care over the last 15 years were associated to an improvement of respiratory outcome and survival, despite a nonsignificant decrease in BPD rate.

Effect of noninvasive positive pressure ventilation on the severe cases of hand foot and mouth disease

Objective To evaluate the effects of noninvasive positive pressure ventilation on the severe cases of hand foot and mouth disease (HFMD).Methods Eighty-six cases of severe HFMD admitted to our hospital between Apr 2009 and Aug 2010 were divided into two groups based on the time when admitted to our hospital.Thirty-eight cases (group A,Apr to Jul,2009) received routine treatment and 48 cases (group B,Apr to Aug,2010) were ventilated with nasal continuous positive airway pressure based on routine treatment.The difference of the total efficiency was compared between two groups.Results Twenty-five out of 38 patients were cured,six showed improved signs,and seven showed no improvement in group A,of which the total efficiency was 81.5％.Forty out of 48 patients were cured,seven showed improved signs,and one showed no improvement in group B,of which the total efficiency was 97.9％.The clinical effect of group B was much better than group A and the difference was statistically significant ( x2 =6.71,P ＜0.05).Conclusion Early nasal continuous positive airway pressure has most valuable effect on HFMD and is helpful in preventing -HFMD from getting worse. Key words: Hand foot and mouth disease; Critical illness; Nasal continuous positive airway pressure

CPAP review

Continuous positive airway pressure (CPAP) is widely used in neonatal units both as a primary mode of respiratory support and following extubation from mechanical ventilation. In this review, the evidence for CPAP use particularly in prematurely born infants is considered. Studies comparing methods of CPAP generation have yielded conflicting results, but meta-analysis of randomised trials has demonstrated that delivering CPAP via short nasal prongs is most effective in preventing re-intubation. At present, there is insufficient evidence to establish the safety or efficacy of high flow nasal cannulae for prematurely born infants. Observational studies highlighted that early CPAP use rather than intubation and ventilation was associated with a lower incidence of bronchopulmonary dysplasia (BPD), but this has not been confirmed in three large randomised trials. Meta-analysis of the results of randomised trials has demonstrated that use of CPAP reduces extubation failure, particularly if a CPAP level of 5 cm H2O or more is used. Nasal injury can occur and is related to the length of time CPAP is used; weaning CPAP by pressure rather than by "time-cycling" reduces the weaning time and may reduce BPD. In conclusion, further studies are required to identify the optimum mode of CPAP generation and it is important that prematurely born infants are weaned from CPAP as soon as possible.

Surfactant, mechanical ventilation or CPAP for treatment of early respiratory failure in preterm infants: A continuing conundrum?

s2view.con/pas/view.php?nu=PAS10L1660. Accessed on January 25, 2010. 4. Sandri F, Plavka R, Simeoni U; CURPAP Advisory Board. The CURPAP study: an international randomized controlled trial to evaluate the efficacy of combining prophylactic surfactant and early nasal continuous positive airway pressure in very preterm infants. Neonatology. 2008;94:60-2. 5. Tsakalidis C, Kourti M, Karayianni P, Rallis D, Porpodi M, Nikolaidis N. Early rescue administration of surfactant and nasal continuous positive airway pressure in preterm infants <32 weeks gestation. Indian Pediatr. 2011;48:601-5.

Impact of providing vitamin A to the routine pulmonary care of extremely low birth weight infants

Objective. The objective of this study was to determine if the continued use of vitamin A in a nursery utilizing early surfactant and nasal continuous positive airway pressure (CPAP) was warranted.Study design. A retrospective, cohort study of appropriately sized, preterm neonates weighing ≤1000 g at birth was conducted. Two time periods were compared: Pre-Vitamin A was composed of extremely low birth weight who were routinely cared for with early nasal CPAP (n = 76); and Post-Vitamin A (n = 102) consisted of ELBWs who were cared for similar to Pre-Vitamin A, but with the addition of vitamin A. Outcome variables included the incidence of BPD and other pulmonary and major neonatal morbidities.Results. Between Pre-Vitamin A and Post-Vitamin A the incidence of moderate to severe BPD decreased by 11%, from 33% to 22% (p = 0.2). No difference was found in the number of ventilator days or in the incidence of any other neonatal morbidity or mortality, including intraventricular hemorrhage, necrotizing enterocolitis, or patent ductus arteriosus requiring surgical ligation.Conclusion. In a neonatal unit utilizing early surfactant followed by nasal CPAP at delivery, supplementing extremely premature neonates with vitamin A demonstrated a trend towards a decrease in the incidence of moderate to severe BPD; however, this change requires a larger sample to verify in the future.

Is mechanical ventilation associated with intraventricular hemorrhage in preterm infants?

BackgroundThe impact of mechanical ventilation on the incidence of intraventricular hemorrhage (IVH) in very low birth weight (VLBW) infants is unknown, simply because the vast majority of these infants have been routinely intubated and mechanically ventilated. There is a growing interest in the use of early nasal continuous positive airway pressure (ENCPAP) and avoiding mechanical ventilation. ObjectivesTo examine the role of mechanical ventilation since delivery room in determining severe IVH in VLBW infants in two neonatal units that follow the same strategy of respiratory management using ENCPAP. MethodsWe collected data on delivery room intubation and mechanical ventilation during the first 3days of life in VLBW infants. Logistic regression model was constructed to test the relationship between early mechanical ventilation and the diagnosis of severe IVH after controlling for significant confounding variables, such as BW, gender, duration of mechanical ventilation, and partial pressure of CO2 (PCO2). ResultsOf the studied 340 VLBW, 35 infants had severe IVH; most of them received mechanical ventilation that started either in the delivery room (n=12) or during the first (n=10) and second (n=3) days of life. Severe IVH was independently associated with lower BW, mechanical ventilation in the delivery room, and the cumulative duration of mechanical ventilation during the first 3days. The adjusted odds ratio for severe IVH in infants intubated in delivery room was (OR=2.7, CI: 1.1–6.6, P=0.03). Severe IVH was not associated with gender, prenatal steroids, early sepsis, or patent ductus arteriosus. ConclusionsMechanical ventilation plays a role in predicting severe IVH. Both the time at which ventilation was initiated and the duration of ventilation are important determinants of severe IVH. Risk for severe IVH in infants who were never intubated in delivery room or during the first 3days of life is miniscule.

Positive airway pressure levels and pneumothorax: a case–control study in very low birth weight infants

Objectives. Evaluate the incidence of pneumothorax (PTx) and the levels of positive airway pressure (Paw) applied to very low birth weight infants during the first 5 days of life (DOL), after evidence-based protocols using early continuous positive airway pressure (CPAP) and high levels of Paw (CPAP or mean airway pressure) were implemented.Methods. From 2004 to 2007, all infants submitted to assisted ventilation that developed PTx were identified. Controls were matched by birth weight, gestational age, and type of ventilatory support. Paw levels were averaged on a time-weighted basis. A p value <0.05 was considered significant.Results. A total of 25 infants developed PTx (3.8%); 23 during the first 5 DOL. PTx was diagnosed at 14 h of life (1.3–80 h) when 74% were treated with mechanical ventilation. In controls, Paw decreased over time whereas in PTx infants it did not decline until after 80 h. PTx infants had an increase in Paw from 12 h up to 6 h prior to the diagnosis.Conclusion. The rate of PTx was low even after the implementation of the protocols. An association between Paw levels and PTx was observed but until the precise time of onset of a PTx can be determined this should be regarded either as an early signal or as an indicator of more severe lung disease.

Identification of Pneumothorax in Very Preterm Infants

To compare respiratory and other morbidities between very preterm infants with and without a pneumothorax and to determine whether infants at higher risk of pneumothorax can be identified early in their course. Preterm infants at 23 to 28 weeks' gestation with pneumothorax were compared with matched control subjects. Demographic and clinical data from birth through the first 72 hours were compared. Sixty-two (9.2%) of 675 infants had pneumothorax. There were no significant differences in the baseline maternal and infant characteristics. Mortality was significantly higher in the pneumothorax group (43%) versus control subjects (13%). There was no significant difference in continuous positive airway pressure or surfactant treatment or rates of intraventricular hemorrhage or bronchopulmonary dysplasia. Infants treated with early continuous positive airway pressure in the delivery room typically had pneumothorax on day 2 of life. Those who had pneumothorax had higher inspired fraction of oxygen before its diagnosis and over the first 12 hours of life than did control subjects. Pneumothorax is associated with increased mortality and with severity of lung disease in the first day of life. It may be possible to identify babies at highest risk of pneumothorax on the basis of inspired fraction of oxygen in the first 12 hours of life.

CPAP combined with inhaled nitric oxide for treatment of lung hypoplasia and persistent foetal circulation due to prolonged PPROM

Background Second trimester preterm premature rupture of the membranes (PPROM) before 24 weeks of gestation is associated with a high morbidity and mortality rate. Aim To demonstrate the efficacy of early continuous positive airway pressure (CPAP) combined with inhaled nitric oxide (iNO) for treatment of preterm infants with lung hypoplasia and persistent foetal circulation (PFC) due to very early PPROM and prolonged severe oligohydramnios. Methods Seven infants with prolonged PPROM, lung hypoplasia, respiratory distress and persistent foetal circulation were intubated in the delivery room for subsequent surfactant and iNO application. As our new treatment strategy was to keep the period of mechanical ventilation as short as possible, all infants were switched on nasal CPAP combined with iNO within the first 24 hours. Results Mean gestational age at PPROM was 19 + 6 weeks (range 14 + 2 to 23 + 6 weeks) and the average latency period between rupture of membranes and delivery was 10 + 3 weeks (7 + 3 to 16 + 4 weeks). Infants were born at 30 + 3 weeks of gestation (28 + 3 to 33 + 1 weeks) with an average birth weight of 1468 g (884 to 2200 g). In all neonates CPAP combined with iNO reversed PFC and 6 patients stabilised without the need for reintubation and mechanical ventilation. One infant had to be reintubated following 12 hours of CPAP combined with iNO due to respiratory insufficiency. All seven infants survived to discharge. Conclusion CPAP combined with iNO might be a promising approach for therapy of preterm infants with lung hypoplasia and persistent foetal circulation due to very early PPROM.

Early nasal continuous positive airway pressure versus INSURE in VLBW neonates

BackgroundEvidence suggests the INSURE strategy (INtubate-SURfactant administration and Extubate to nasal continuous positive airway pressure [nCPAP]) is superior to mechanical ventilation (MV) with rescue surfactant for the management of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates. There is limited data, however, to assess whether INSURE is superior to nCPAP alone. We aimed to compare these two strategies regarding early and late outcomes. MethodsRetrospective cohort study from Jan/2002 to Aug/2008. We included VLBW neonateswith gestational age (GA) ≤ 30 weeks registered in the Vermont Oxford Network that used either nCPAP alone (nCPAP group, N=40), or with INSURE (INSURE group, N=56). We assessed early (RDS, need for rescue surfactant, and CPAP failure with MV) and late outcomes (chronic lung disease of prematurity (CLD), mortality, and composite outcome of mortality and/or CLD). ResultsNeonates in the INSURE group had lower mean GA, while other baseline variables were comparable. The proportion of RDS was significantly superior in the nCPAP group (53% vs. 30%; adjusted OR [95% CI] – 0.2 [0.1-0.6]). Therapeutic surfactant was administered to all cases with RDS in the nCPAP group, but to none from the INSURE group. MV was more frequently required in the nCPAP group (11/ 40, 28% vs. 9/ 56, 12%; p=0.04). No statistically significant differences were found in either of the late outcomes. ConclusionThe use of nCPAP alone in VLBW neonates with GA ≤ 30 weeks may be associated with slightly poorer early outcomes than the INSURE strategy, but there were no significant differences in CLD or mortality.

Early CPAP versus Surfactant in Extremely Preterm Infants

Background There are limited data to inform the choice between early treatment with continuous positive airway pressure (CPAP) and early surfactant treatment as the initial support for extremely-low-birth-weight infants. Methods We performed a randomized, multicenter trial, with a 2-by-2 factorial design, involving infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation. Infants were randomly assigned to intubation and surfactant treatment (within 1 hour after birth) or to CPAP treatment initiated in the delivery room, with subsequent use of a protocol-driven limited ventilation strategy. Infants were also randomly assigned to one of two target ranges of oxygen saturation. The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks (with an attempt at withdrawal of supplemental oxygen in neonates who were receiving less than 30% oxygen). Results A total of 1316 infants were enrolled in the study. The rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group (47.8% and 51.0%, respectively; relative risk with CPAP, 0.95; 95% confidence interval [CI], 0.85 to 1.05) after adjustment for gestational age, center, and familial clustering. The results were similar when bronchopulmonary dysplasia was defined according to the need for any supplemental oxygen at 36 weeks (rates of primary outcome, 48.7% and 54.1%, respectively; relative risk with CPAP, 0.91; 95% CI, 0.83 to 1.01). Infants who received CPAP treatment, as compared with infants who received surfactant treatment, less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia (P<0.001), required fewer days of mechanical ventilation (P=0.03), and were more likely to

Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy

Although chemotherapy and transplantation improve outcome of patients with hematological malignancy, complications of these therapies are responsible for a 20-50% mortality rate that increases when respiratory symptoms evolve into acute lung injury (ALI). The aim of this study is to determine the effectiveness of early continuous positive airway pressure (CPAP) delivered in the ward to prevent occurrence of ALI requiring intensive care unit (ICU) admission for mechanical ventilation. Patients with hematological malignancy presenting in the hematological ward with early changes in respiratory variables were randomized to receive oxygen (N = 20) or oxygen plus CPAP (N = 20). Primary outcome variables were need of mechanical ventilation requiring ICU admission, and intubation rate among those patients who required ICU admission. At randomization, arterial-to-inspiratory O(2) ratio in control and CPAP group was 282 ± 41 and 256 ± 52, respectively. Patients who received CPAP had less need of ICU admission for mechanical ventilation (4 versus 16 patients; P = 0.0002). CPAP reduced the relative risk for developing need of ventilatory support to 0.25 (95% confidence interval: 0.10-0.62). Among patients admitted to ICU, intubation rate was lower in the CPAP than in the control group (2 versus 14 patients; P = 0.0001). CPAP reduced the relative risk for intubation to 0.46 (95% confidence interval: 0.27-0.78). This study suggests that early use of CPAP on the hematological ward in patients with early changes in respiratory variables prevents evolution to acute lung injury requiring mechanical ventilation and ICU admission.

Pulmonary air leaks and NCPAP failure in late preterm infants with respiratory distress

Aims: To study incidence and type of pulmonary air leak in preterm infants with respiratory distress treated with early nasal continuous positive airway pressure (NCPAP) and to assess risk factors for NCPAP-failure. Methods: A prospective, observational, single center study from August 2007 to November 2008. Early NCPAP using Infant Flow CPAP system was started in patients with a median (range) postnatal age of 1.47 (0.5-11) hours. A written NCPAP protocol including chest x-ray was applied to detect early signs of air leak. Babies were intubated when their FiO2 requirements were > 0.35. Results: 54 neonates, 45 with respiratory distress syndrome and 9 with transient tachypnea of the newborn, were studied with a gestational age of 33.6 ± 1.1 weeks and a birthweight of 2026± 303 gm (mean± SD). A total of five infants had air leak (9.3%), one of them developed pneumothorax (1.8%) and four infants had transient pulmonary interstitial emphysema (7.4%). NCPAP- failure rate was 48.1%. The single case with pneumothorax was discovered only after being intubated and surfactant was administered. Conclusion: Early NCPAP/low threshold rescue surfactant policy in preterm infants > 32 weeks of gestation with respiratory distress was associated with a 9.3% incidence of air leak, mainly in the form of pulmonary interstitial emphysema. Clinical variables significantly associated with NCPAP- failure wer e RDS and early onset sepsis.

Estratégias de suporte ventilatório no recém-nascido pré-termo – Inquérito nacional (2008)

Background: Respiratory support strategies for the preterm newborn have been the subject of intense research.Aim: To survey neonatal respiratory support practices in Portugal and to determine whether they reflect evidence from randomised trials.Methods: Questionnaires were given out to 31 Portuguese neonatal units to determine the types of ventilators, modes of ventilation, lung function monitoring, use of exogenous surfactant, oxygen saturation levels used and the prevalence of chronic lung disease in the preterm newborn.Results: There was a 94% response rate. Draeger babylog was the most frequently used ventilator in neonates. Twelve (41%) units prefer to use early nasal continuous positive airway pressure (NCPAP) whenever possible. Triggered ventilation is the choice of invasive ventilation in 24 (83%) units (SIMV, SIPPV, PSV); four (14%) units have high frequency oscillation ventilation. SIMV is the most frequent (n=13, 45%) weaning mode. Exogenous surfactant is used as prophylactic in 12 (41%) units. All units use lung function measurements to aid choice of ventilator settings and five (17%) units monitor PaCO2 (transcutaneous=3; capnometry=2). Seventeen (59%) units allow oxygen saturation levels from 90% to 95% in infants with respiratory distress syndrome and 15 (52%) levels from 85% to 90% in infants with chronic lung disease. Prevalence of chronic lung disease of prematurity ranged from 0% to 75% (median: 10).Conclusions: Many respiratory strategies for extremely low birth weight infants reflect the result of large randomised trials. More effective methods may be required to encourage the use of early NCPAP preferably with binasal prongs, the use of SIPPV as the main weaning mode, the use of volume targeted ventilation and a more judicious use of exogenous surfactant in order to ensure evidence–based practice.Rev Port Pneumol 2009; XV (6): 1043-1071