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Nasal CPAP or intubation at birth for preterm infants
  1. Alex Shalshin
  1. Dr A Shalshin, Department of Pulmonary Critical Care Medicine, Department of Medicine, Winthrop University Hospital, Mineola, NY, USA; shalshin{at}

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Bronchopulmonary dysplasia, resulting from damage to the lungs caused by ventilation, remains a major cause of mortality in preterm infants. In this international multicentre study the investigators compared continuous positive airway pressure (CPAP) with intubation in preterm infants (infants born at 25–28 weeks’ gestation) to assess whether avoidance of ventilation reduced the incidence of bronchopulmonary dysplasia.

A total of 610 infants were randomised to receive nasal CPAP or intubation and ventilation if, 5 min after birth, the clinician leading the resuscitation decided continuing respiratory support was necessary. The demographic characteristics of the two groups were similar. Nasal CPAP was started at 8 cm H2O and adjusted as needed. The primary outcome of the study was death or bronchopulmonary dysplasia (defined as the need for oxygen treatment at 36 weeks’ gestational age). Secondary outcomes included the use of oxygen treatment at 28 days and the incidence of intubation.

The results were reviewed at 28 days, 36 weeks and before discharge, and showed a minimal difference in overall mortality between the two groups. Although the CPAP group had fewer days of ventilation, required a lower rate of oxygen treatment at 28 days and the use of surfactant was reduced, they had a higher risk of pneumothorax.

This study did not identify CPAP as a significant agent to reduce death or rates of bronchopulmonary dysplasia compared with intubation. The authors point out that it also does not help to identify infants at birth who, if treated with CPAP, will subsequently require intubation and ventilation. However, CPAP does not appear to affect infants adversely, even if they are subsequently ventilated.

Morley CJ, Davis PG, Doyle LW, et al, for the COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008;358:700–8.