The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

EARLY USE OF NASAL CPAP (NCPAP) IN EXTREMELY PRETERM INFANTS: CAN SEQUELAE OF POSITIVE PRESSURE VENTILATION (PPV) BE REDUCED?

Christine Kelly, MPA, RRT, Pablo Cababaan, CRTT, and Lucille Lew, RRT Respiratory Care Service UCSF Children's Hospital at UCSF Medical Center

INTRODUCTION: It is well known that intubation and positive pressure ventilation can lead to lung injury in preterm infants, which is still the primary cause of morbidity in this patient group. Complications from invasive positive pressure ventilation include (but are not limited to) chronic lung disease (CLD), intraventricular hemorrhage (IVH), and pneumonia (PNA). There is some evidence to suggest that non-intubation or early extubation of preterm infants might reduce these sequelae. It is uncertain whether this applies to the extremely preterm (24 - 29 weeks gestational age) population. We wanted to determine whether rapid extubation and use of early NCPAP would produce a lower complication rate in extremely preterm infants, when compared to those remaining on invasive positive pressure ventilation for a longer period of time. 

METHOD: A retrospective study was designed to collect data on all inborn preterm infants 24-29 weeks gestational age at birth. We selected a similar six-month time period pre- and post- initiation of early extubation to determine if a change in practice led to improved outcome. Patients admitted to the Intensive Care Nursery between June 1, 2001 and December 1, 2001 were compared to those admitted June 1, 2002 and December 1, 2002 after early extubation and early use of NCPAP was implemented. NCPAP was delivered using a fluidic system. All infants with pre-existing congenital conditions were eliminated from the study. All mothers received at least one dose betamethasone prior to delivery.

RESULTS: A total of 23 patients met criteria for inclusion in this study. The data below summarize our findings:

 Mean values pre-and post-initiation of early extubation and early use of NCPAP

Total #pts GA/Wt Year PPV NCPAP PNA CLD IVH
 11 (pre) 27 w/962 g 2001 16.9 days 5 days 3 2 5
 12 (post) 27 w/817 g 2002 8.7 days 22 days 1 1 2


 Percentage reduction in mechanical ventilation days and adverse effects with early NCPAP

Vent Days Pneumonia Chronic Lung Disease Intraventricular hemorrhage
49% 70% 56% 62%


CONCLUSION: Our data suggest that there is an association between reduction in days on mechanical ventilation and a decline in sequelae of CLD, IVH, and PNA. In this study, the group of patients started on early NCPAP had an average weight that was 145 grams less than the "pre-early extubation group". This was a factor in the extending the days on NCPAP for the early extubation group. During the change in respiratory management of the extremely preterm infant, we found that discontinuing NCPAP prior to an infant reaching 1000 grams resulted in loss of weight and more apnea and bradycardia episodes. It was decided to keep this population on NCPAP for a longer period of time to minimize apneas and bradycardias and improve weight gain. There are ongoing studies to substantiate that there is reduction in adverse effects with early extubation for the extremely preterm infant.

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