PRESSURe: supporting PREterm infantS respiration using physiological-based CPAP at birth.

Abstract

Objectives: Preterm infants typically receive CPAP levels of 5-8 cmH2O at birth, which may be insufficient for effective lung liquid clearance. It is suggested that initiating with higher CPAP levels, followed by down-titration after stabilization (physiological-based CPAP; PB-CPAP) can improve lung aeration. This study evaluated the feasibility of implementing a PB-CPAP guideline in preterm infants at birth. Method(s): We conducted an observational cohort study including infants <32 weeks' gestation at LUMC. PB-CPAP was implemented with an initial level of 12 cmH2O, reduced to 10 cmH2O after stabilization (FiO2<0.4, SpO2>85%, heart rate>100 bpm), and to 8 cmH2O at NICU transfer. Feasibility was defined as successful completion of these titration steps. Clinical outcomes of infants born after implementation were compared with a matched historical cohort (sex, birthweight, delivery mode) receiving standard-CPAP (5-8 cmH2O). Result(s): All 32 infants in the PB-CPAP group received initial CPAP of 12cmH2O, which was reduced to 10 cmH2O. Stabilization time was recorded in 16/32 infants (334.9 +/- 95.7s after birth), it was unavailable in 16/32 infants and occurred after 10 min in 2/32 infants. Relative to individual stabilization time, CPAP was reduced to 10 cmH2O at a median (IQR) of 35(72-18) seconds before stabilization in 6 infants, and at 0(0-6) seconds after stabilization in 7 infants. CPAP was further reduced to 8 cmH2O at NICU transfer in 19/32 (59%) infants, while 9/32 (28%) remained at 10 cmH2O at clinician discretion. Positive pressure ventilation was required in 17/32 infants; no pneumothoraxes were observed. Seventeen PB-CPAP infants were matched 1:1 to standard-CPAP infants. The PB-CPAP group reached SpO2 > 80% faster than the standard CPAP group [136.5(66.0)s vs 223.1(151.2)s, p = 0.020]. Conclusion(s): A stepwise physiological-based CPAP protocol can be implemented in preterm infants, although adherence to all titration steps was variable. Its use was associated with faster improvement in oxygenation in a small matched cohort.