Introduction
Preterm neonates are at high risk of developing respiratory distress (RD) in the immediate post-natal period. Traditionally, these infants are managed by intubation and mechanical ventilation. The risks of mechanical ventilation to premature lungs are well known. Even a brief exposure to large volume breaths can initiate an inflammatory cascade leading to bronchopulmonary dysplasia (BPD).
Avoiding intubation in the delivery room and stabilization with nasal continuous positive airway pressure (NCPAP) improves outcomes. Recently, use of CPAP is becoming the first-line treatment in preterm infants at birth, reducing the need for mechanical ventilation and surfactant replacement.
However, NCPAP failure rates remain unacceptably high, with many newborns requiring secondary mechanical ventilation as well as delayed surfactant administration, with increased risk of mortality and major morbidity. Several reports have suggested that NCPAP failure is associated with a higher risk of adverse outcomes, including pneumothorax, BPD and intraventricular hemorrhage (IVH), than the group for whom NCPAP successfully avoids intubation.
Identifying infants at risk for NCPAP failure could help target early interventions to avoid intubation and MV. Several factors associated with NCPAP failure have been proposed in the literature, mainly lower gestational age, birth weight, oxygenation parameters in the first hours of life and the presence of severe respiratory distress syndrome (RDS) on the initial chest radiograph. However, there is still a need to evaluate the modifiable risk factors that result in NCPAP failure.