No significant difference in mortality among premature infants treated with continuous positive airway pressure (CPAP) versus surfactant
Jan 17th – There was no significant difference in a composite outcome of mortality or neurodevelopmental impairment among extremely premature infants treated with CPAP or surfactant administration.
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1. There was no significant difference in a composite outcome of mortality or neurodevelopmental impairment among extremely premature infants treated with CPAP or surfactant administration.
2. There was no significant difference in a composite outcome of mortality or neurodevelopmental impairment in infants assigned to lower or higher target-oxygenation levels.
There was no significant difference in the composite outcome of death or neurodevelopmental impairment among premature infants treated with CPAP versus surfactant and low versus high-oxygen saturation levels. These results suggest that less invasive ventilation treatments for premature infants such as CPAP can be considered as an alternative option. Higher-oxygen saturation goals were associated with a lower mortality rate, although they also were associated with a higher incidence of retinopathy of prematurity (of note, overall visual impairment was not significantly different at 18-22 months). While this study yielded valuable information with regard to therapeutic options for extremely premature infants, continued long-term follow up of these infants will shed further light on the issue. Studies are already in place to examine long-term neurodevelopmental outcomes beyond the 18-22 month timeframe used in this study. Nonetheless, this study indicates that early CPAP may be as effective as surfactant while also reinforcing the notion that higher oxygen saturation targets are associated with a lower mortality for extremely premature infants.
Click to read the study in NEJM
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1. There was no significant difference in a composite outcome of mortality or neurodevelopmental impairment among extremely premature infants treated with CPAP or surfactant administration.
2. There was no significant difference in a composite outcome of mortality or neurodevelopmental impairment in infants assigned to lower or higher target-oxygenation levels.
Primer: Fetal lung development is one of the most critical concerns in the care of premature infants. Underdeveloped lungs represent a primary cause of serious complications after birth including bronchopulmonary dysplasia, congenital lobar emphysema, and death. Fetal lung development begins during the fourth week of pregnancy and the lungs begin producing surfactant at approximately 23 weeks of gestation. Surfactant acts in the fetal lung to increase pulmonary compliance and to prevent atelectasis. By approximately the 33rd week of gestation, the lungs are nearly completed developed. Therefore, infants born before 33 weeks likely require intervention by way of continuous positive airway pressure (CPAP) or delivery of surfactant. In this article, the authors compared the use of CPAP or surfactant administration, as well as different target levels of oxygenation, on infant mortality and neurodevelopmental outcomes in premature infants.
Background reading:
- UpToDate: Short term complications of the premature infant
- Are outcomes of extremely preterm infants improving? Impact of Bayley Assessment of Outcomes
This [multi-center, randomized control trial] study: This study enrolled 1,316 preterm infants with a gestational age range of 24 weeks to 27 weeks and 6 days. The infants were randomized to both a limited ventilation strategy (CPAP versus surfactant) and a target-oxygenation range (85-89% or 91-95%). A total of 258 infants died before 18-22 months of age and 92% of these deaths occurred before discharge following birth.
Overall the primary endpoint of composite outcome of death or neurodevelopmental impairment at 18-22 months did not significantly differ between the CPAP versus surfactant groups or between the target oxygenation groups. Only looking at mortality, it did not significantly differ between the CPAP and surfactant group. Mortality alone, however, was observed to be significantly higher in the lower-oxygen saturation group versus the higher-oxygen group. In subset analysis of the lower-gestational age cohort, mortality was statistically significantly higher in the surfactant group in comparison to the CPAP group.
In sum: There was no significant difference in the composite outcome of death or neurodevelopmental impairment among premature infants treated with CPAP versus surfactant and low versus high-oxygen saturation levels. These results suggest that less invasive ventilation treatments for premature infants such as CPAP can be considered as an alternative option. Higher-oxygen saturation goals were associated with a lower mortality rate, although they also were associated with a higher incidence of retinopathy of prematurity (of note, overall visual impairment was not significantly different at 18-22 months). While this study yielded valuable information with regard to therapeutic options for extremely premature infants, continued long-term follow up of these infants will shed further light on the issue. Studies are already in place to examine long-term neurodevelopmental outcomes beyond the 18-22 month timeframe used in this study. Nonetheless, this study indicates that early CPAP may be as effective as surfactant while also reinforcing the notion that higher oxygen saturation targets are associated with a lower mortality for extremely premature infants.
Click to read the study in NEJM
By [BH] and [RR]
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Brittany Hasty: Brittany is a 3rd year M.D. candidate at Boston University in Boston, Massachusetts.
Rif Rahman: Rif is a 4th year M.D. candidate at Harvard Medical School.
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