For the critical outcome of death or bronchopulmonary dysplasia, we identified moderate-quality evidence (downgraded for risk of bias) from 3 randomized clinical trials (Morley 2008, 700; Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) enrolling 2358 preterm infants born at less than 30 weeks of gestation in the first 15 minutes after birth showing potential benefit to starting treatment with CPAP (RR, 0.91; 95% CI, 0.83–1.00). For the critical outcome of death, we identified moderate-quality evidence (downgraded for risk of bias, imprecision) from the same 3 randomized clinical trials (Morley 2008, 700; Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) showing no benefit to starting treatment with CPAP (RR, 0.82; 95% CI, 0.66–1.03). However, we recognize that while the point estimate would suggest potential for benefit, the confidence intervals cross unity to 1.03, suggesting that the potential for harm is minimal. For the critical outcome of bronchopulmonary dysplasia, we identified moderate-quality evidence (downgraded for indirectness) from the same 3 randomized clinical trials (Morley 2008, 700; Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) showing no benefit to starting treatment with CPAP (RR, 0.92; 95% CI, 0.82–1.03). However, we recognize that while the point estimate would suggest potential for benefit, the confidence intervals cross unity to 1.03, suggesting that the potential for harm is minimal. For the critical outcome of air leak, we identified very-low-quality evidence (downgraded for inconsistency and very serious imprecision) from the same 3 randomized clinical trials(Morley 2008, 700; Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) showing no benefit to starting treatment with CPAP (RR, 1.24; 95% CI, 0.91–1.69). For the critical outcome of severe IVH, we identified very-low-quality evidence (downgraded for inconsistency and serious imprecision) from the same 3 randomized clinical trials(Morley 2008, 7008; Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) showing no benefit to starting treatment with CPAP (RR, 1.09; 95% CI, 0.86–1.39).For the important outcome of necrotizing enterocolitis, we identified moderate-quality evidence (downgraded for imprecision) from the same 3 randomized clinical trials (Morley 2008, 700; Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) showing no benefit to starting treatment with CPAP (RR, 1.19; 95% CI, 0.92–1.55). For the important outcome of severe retinopathy of prematurity, we identified low-quality evidence (downgraded for very serious imprecision) from 2 randomized clinical trials (Support Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network 2010, 1970; Dunn 2011, e1069) enrolling 1359 infants showing no benefit to starting treatment with CPAP (RR, 1.03; 95% CI, 0.77–1.39). |
For spontaneously breathing preterm infants with respiratory distress requiring respiratory support in the delivery room, we suggest initial use of CPAP rather than intubation and IPPV (weak recommendation, moderate-quality evidence).Values, Preferences, and Task Force InsightsIn making this suggestion, we recognize that the absolute reduction in risk of adverse outcome associated with starting with CPAP is small and that infants recruited to the trials had a high rate of treatment with antenatal steroids but we value the less invasive approach. CPAP was introduced in 2010 CoSTR as an option to be considered for babies who are breathing, but breathing with difficulty. The previous recommendation had been to simply administer blow-by oxygen. The current PICO question did not address the option of using no support. There was a consensus that, in the absence of contrary evidence, administration of CPAP, with or without supplementary targeted oxygen, is preferable in this situation if resources permit. |
