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Continuous positive airway pressure failure in preterm infants: incidence, predictors, and consequences1 

 

Dargaville, P. A., Aiyappan, A., De Paoli, A. G., Dalton, R. G., Kuschel, C. A., Kamlin, C. O., Orsini, F., Carlin, J. B., & Davis, P. G. (2013). Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences. Neonatology, 104(1), 8–14.

 

Introduction

 
 

The study examined the outcomes of using nasal continuous positive airway pressure (CPAP) as the initial respiratory support for preterm infants. CPAP had been increasingly used without prior intubation and surfactant therapy for preterm infants born at ≤32 weeks of gestation.1,2

 


However, a proportion of these infants fail CPAP, requiring intubation and ventilation.3–6 The research aimed to determine the incidence, predictors and outcomes of CPAP failure.1 

 

Study design:

 

The study was conducted at the Royal Hobart Hospital (RHH) and the Royal Women’s Hospital, Melbourne (RWH), focusing on preterm infants born at 25–32 weeks gestational age (GA) who were admitted to the neonatal intensive care unit (NICU) within 24 hours of birth and initially managed with CPAP. Infants requiring CPAP pressures >8 cm H₂O and FiO₂ >0.45–0.50 were intubated and given exogenous surfactant if indicated.

 

Exclusion criteria included immediate intubation after birth, cases complicated by premature rupture (≥14 days), or congenital anomalies affecting respiratory function or care. Infants were analysed in two groups based on GA (25–28 weeks and 29–32 weeks) and further subdivided by CPAP success or failure (Figure 1). 

 

Adapted from Dargaville, et al. 2013 

 

Results:1

 
 

A total of 297 infants 25–32 weeks’ gestation were treated initially with CPAP. 

 

Out of 297 preterm infants studied, 22% (65 infants) failed CPAP, with a higher failure rate observed in infants born at earlier gestations. Specifically, 45% of infants born at 25–28 weeks failed CPAP, compared to 15% of those born at 29–32 weeks. Infants failing CPAP were often of lower birth weight and more likely delivered via caesarean section (Figure 1). 

 

The median age of CPAP failure was 7.9 hours for the 25–28 weeks group and 18 hours for the 29–32 weeks group. Infants failing CPAP had relatively high CPAP levels and oxygen requirements at the time of intubation, with FiO₂ levels around 0.5 for the 25–28 weeks group and 0.44 for the 29–32 weeks group. Radiological assessments showed moderate to severe respiratory distress syndrome (RDS) in most CPAP failure cases (Table 2).

 

FiO2 as a predictor of CPAP failure: 

 

Early-life FiO₂ was the strongest predictor of CPAP failure in both gestational groups, with caesarean delivery also independently significant. Adding CPAP level improved predictions for 25–28 weeks but not for 29–32 weeks. At both gestation ranges, ROC curves showed that FiO2 in early life appeared to be a good predictor of CPAP failure, with an area under the curve of at least 0.8 and threshold of ~0.3 balancing sensitivity and false-positive rates (Figure 2).

 

CPAP failure is associated with adverse outcomes: 

 

Infants failing CPAP had considerably prolonged durations of respiratory support and oxygen therapy compared to those who succeeded. Among infants aged 29–32 weeks, the median duration was 6.3 days (IQR 4.4–8.5) in the CPAP-F group versus 1.4 days (IQR 0.66–3.8) in the CPAP-S group. For those aged 25–28 weeks, the median duration was 50 days (IQR 11–60) in the CPAP-F group compared to 10 days (IQR 3.6–32) in the CPAP-S group (Figure 3).

 

At 25–28 weeks’ GA, rates of BPD, death or BPD, major morbidity and NEC were considerably higher in infants who failed CPAP compared to those who succeeded. Incidence of BPD was 40% and 14% in the two groups, respectively (RR: 2.9, 95% CI 1.1, 7.3), and of death or BPD 53% and 14% (RR: 3.8, 95% CI 1.6, 9.3). The risk of these outcomes in the infants who failed CPAP was comparable with those intubated primarily, in whom the incidence of BPD was 28% (p=0.23 compared with those who failed CPAP) and of death or BPD 43% (p=0.35). 

 

For infants with GA 29–32 weeks, CPAP failure was associated with a substantially higher risk of pneumothorax than those who succeeded.

Conclusion:

 

The study concluded that CPAP failure in preterm infants usually occurs because of unremitting RDS, and is predicted by an FiO2 of ≥0.3 — a value adopted by European guidelines.1,7 

 

Infants failing CPAP had considerably prolonged durations of respiratory support and oxygen therapy, and a substantially increased risk in adverse outcomes, including BPD and major morbidity at 25–28 weeks, and pneumothorax at 29–32 weeks.

 

 
 
 

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Abbreviations

 

AUC, area under the curve; BPD, bronchopulmonary dysplasia; cm H₂O, centimetres of water; CI, confidence interval; CPAP, continuous positive airway pressure; FiO₂, fraction of inspired oxygen; GA, gestational age; h, hours; IQR, interquartile range; NEC, necrotising enterocolitis; NICU, neonatal intensive care unit; PTX, pneumothorax; ROC, receiver operating characteristic; RDS, respiratory distress syndrome; RR, relative risk.

 
 

References

  1. Dargaville PA, et al. Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences Neonatology. 2013;104(1):8–14. 
  2. Finer N: To intubate or not – that is the question: continuous positive airway pressure versus surfactant and extremely low birth weight infants. Arch Dis Child Fetal Neonatal Ed 2006; 91:F392–F394. 
  3. Ammari A, Suri M, Milisavljevic V, Sahni R, Bateman D, Sanocka U, Ruzal-Shapiro C, Wung JT, Polin RA: Variables associated with the early failure of nasal CPAP in very low birth weight infants. J Pediatr 2005; 147: 341– 347. 
  4. Aly H, Massaro AN, Patel K, El Mohandes AA: Is it safer to intubate premature infants in the delivery room? Pediatrics 2005; 115: 1660– 1665. 
  5. Fuchs H, Lindner W, Leiprecht A, Mendler MR, Hummler HD: Predictors of early nasal CPAP failure and effects of various intubation criteria on the rate of mechanical ventilation in preterm infants of <29 weeks gestational age. Arch Dis Child Fetal Neonatal Ed 2011; 96:F343–F347. 
  6. De Jaegere AP, van der Lee JH, Cante C, van Kaam AH: Early prediction of nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation. Acta Paediatr 2011; 101: 374–379. 
  7. Sweet DG, Carnielli VP, Greisen G, et al. European consensus guidelines on the Management of Respiratory Distress Syndrome: 2022 update. Neonatology. 2023;120(1):3-23. 
 
 

IE-CUR-2500004 | May 2025

 

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