AAP Backs CPAP Plus Selective Surfactants in Preemies

Steven Fox

December 30, 2013

In preterm infants, continuous positive air pressure (CPAP) begun soon after birth, followed by selective use of surfactants, may be an effective alternative to routine intubation coupled with prophylactic or early surfactants, according to a new policy statement issued by the American Academy of Pediatrics (AAP).

The statement appears in the January issue of Pediatrics.

Present practice guidelines recommend use of surfactants at or soon after birth in preterm infants with symptoms of respiratory distress syndrome (RDS).

However, the AAP's Committee on Fetus and Newborn notes that recent multicenter randomized controlled trials have shown that CPAP may be an effective alternative to prophylactic or early surfactant administration in preemies with RDS.

"Respiratory support is being achieved more frequently with CPAP and other less invasive approaches, such as the technique of intubation, surfactant, and extubation," the committee writes.

Moreover, the committee notes that existing data show that mechanical ventilation can cause lung injury, especially when used in the presence of surfactant deficiency.

They note that early trials showed that surfactant use in infants with RDS helped reduce mortality and bronchopulmonary dysplasia, as well as pneumothorax. Subsequent studies found that compared with preemies in whom surfactant administration was delayed, those who received surfactants early on experienced lower rates of pneumothorax, pulmonary interstitial emphysema, bronchopulmonary dysplasia, and death.

On the basis of the committee's review of the literature, they reach several conclusions:

  • When compared with prophylactic or early surfactant therapy, early use of CPAP, coupled with subsequent selective use of surfactants, results in lower rates of bronchopulmonary dysplasia and death.

  • Preterm infants managed with early CPAP alone are at no increased risk for adverse outcomes if treatment with surfactants is delayed or is not administered.

  • Initiating CPAP early may help reduce the duration of mechanical ventilation and postnatal corticosteroid therapy.

  • Presentation of RDS in infants may vary significantly in terms of the severity of disease, maturity, and presence of other complications. For that reason, care should be individualized.

  • Because management of preemies with respiratory difficulties is provided in a wide variety of settings, capabilities of the specific healthcare team need to be considered.

The committee also recommends, "If it is likely that respiratory support with a ventilator will be needed, early administration of surfactant followed by rapid extubation is preferable to prolonged ventilation."

The authors have disclosed no relevant financial relationships.

Pediatrics. 2014;133:171-174.

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