CPAP Failure in Neonates: Practice, Experience, and Focus Do Matter!
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EDITORIAL COMMENTARY
CPAP Failure in Neonates: Practice, Experience, and Focus Do Matter! Sindhu Sivanandan 1 & M Jeeva Sankar 2 Received: 10 September 2020 / Accepted: 10 September 2020 # Dr. K C Chaudhuri Foundation 2020
Continuous positive airway pressure (CPAP) is a simple, noninvasive, and cost-effective therapy, particularly for preterm neonates with respiratory distress syndrome (RDS). It decreases the need for mechanical ventilation as well as the risks of mortality and bronchopulmonary dysplasia (BPD). However, 20–40% of neonates initiated on CPAP might fail and require intubation and mechanical ventilation [1]. The consequences of such CPAP failure are severe, including a significantly higher risk of mortality, intraventricular hemorrhage, and BPD [2]. Early identification of neonates who are at-risk of CPAP failure allows for selective use of mechanical ventilation, thereby reducing the risk of complications. In this issue of the Journal, Murki and colleagues [3] have published a retrospective study on the predictors of early CPAP failure among 652 preterm neonates with respiratory distress admitted in their center over the last decade or so. Of these, 14.7% had early CPAP failure, defined as the need for mechanical ventilation within 72 h of birth. Adjusting for the gestation and year of study, the authors identified the delay in initiation of CPAP, need for surfactant therapy, delay in surfactant administration, and higher initial fractional inspired oxygen (FiO2) concentration as the significant predictors of CPAP failure. Not surprisingly, the risk of neonatal morbidities and the duration of hospital stay were higher in neonates who failed CPAP. The predictors of CPAP failure observed are not very different from those reported by earlier studies [2, 4, 5]. Broadly, the predictors reported in the literature can be grouped into (1) baseline characteristics like gestation, birth weight, and need for resuscitation at birth; (2) severity of respiratory distress, including high respiratory distress scores, chest radiographic
* M Jeeva Sankar [email protected] 1
Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
2
Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India
findings, FiO2 requirement in the initial hours of life, need for surfactant, and blood gas parameters; and (3) managementrelated issues, including the delay in initiation of CPAP, delay in surfactant administration, and skills and experience of healthcare providers in providing CPAP [4, 6, 7]. However, none of these predictors or prediction scores can replace an astute clinician – physician or nurse – standing by the bedside and monitoring the neonate continuously to identify and rescue that occasional infant failing CPAP. What then, are the practical implications of the findings of the present study? Given the reasonably large literature on the predictors of CPAP failure and the increasing experience
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