Does CPAP work when it really matters?

Acta Pædiatrica ISSN 0803–5253

EDITORIAL

Does CPAP work when it really matters?Hugo Lagercrantz (hugo.lagercrantz@actapaediatrica.se)Karolinska Institute, Astrid Lindgren Children’s Hospital, Stockholm, Sweden

CorrespondenceHugo Lagercrantz, Karolinska Institute, AstridLindgren Children’s Hospital, Stockholm, Sweden.Tel: +46 8 517 728 25 | Fax: +46 8 517 740 34 |Email: hugo.lagercrantz@actapaediatrica.se

DOI:10.1111/j.1651-2227.2007.00269.x

Twenty years ago Avery et al. (1) reported that a significantlylower incidence of bronchopulmonary dysplasia (BPD) wasfound at the Columbia University as compared with otherleading North American centres. The proposed explanationwas that the neonatologists at Columbia avoided intuba-tion and used more CPAP instead of mechanical ventilation.In Denmark, Kamper et al. (2) confirmed that infants witha gestational age of more than 25 weeks survive withoutuse of intubation and mechanical ventilation with compar-atively low incidence of BPD. The latter study was attackedby Roberton (3) in a viewpoint entitled: “Does CPAP workwhen it really matters?” In his highly negative commentary,he concluded that `the fundamental concept of the Kamperstudy that the “softly-softly” approach will decrease morbid-ity is, I believe, therefore, from a theoretical point of viewfundamentally flawed’.

After fourteen years one would expect that the battlewas over between the hardline neonatologists mainly inNorth America and the UK, and the ”softy-softy” Danesand Swedes with the Columbia neonatologists. The formerfavour the real stuff – tubes and mechanical ventilators whilethe latter shun early intubation and minimize artificial ven-tilation. In the January issue of Acta Paediatrica, Vanpee etal. (4) reported an incidence at 40 weeks corrected age ofmoderate/severe BPD of 22% in Stockholm compared with40% in Boston (p < 0.05), possibly related to a considerablylower rate of intubation and less mechanical ventilation inStockholm. In a commentary, Jobe (5) is still sceptical to-wards the Scandinavian approach. Although he accepts thatthe incidence of BPD is lower in the Swedish than in theAmerican centre, he makes a point of a higher incidence ofsevere BPD in Stockholm. However, this may be due to thedefinition of severe BPD. Infants in Stockholm often con-tinue with CPAP for thorax stabilization. Thus the presenceof CPAP even with room air has a great effect on the BPDseverity scoring, both at 36 and 40 weeks. When looking atthe workshop definitions of BPD and severity scoring onewonders if it really is appropriate to group mechanical ven-tilation and CPAP together when assessing BPD severity?

It is surprising that this controversy has not yet been solvedby a meta-analyses of randomized control trials (RCT). Mypersonal view is that it is not so easy to solve this problemwith a RCT. To perform a good RCT it is necessary to havestaff with a long experience of both mechanical ventilationand CPAP. The results of a RCT can be significantly biasedby method imbalance due to lack of CPAP experience ina participating centre. A CPAP protocol that is known towork properly should be a prerequisite for centres partakingin RCT’s that aim to compare mechanical ventilation andCPAP strategies. As an example relating to CPAP care, it isrelatively common that centres report nasal sores with CPAPuse, something that is very rarely seen in Scandinavia.

The topic is reviewed again in this issue of Acta Paediatricaby H Verder (6), one of the leading CPAP authorities. He iscareful in his conclusions whether CPAP really reduces theincidence of BPD. He points out that we should master alltechnology and methods available to us, but should not doless or more than is required for the individual baby. Heclaims rightly that nasal CPAP requires less sedation andallows early and very positive mother–child contact. It isalso more cost effective.

References

1. Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, CottonRB. Is chronic lung disease in low birth weight infants pre-ventable? A survey of eight centers. Pediatrics 1987; 79: 26–30.

2. Kamper J, Wulff K, Larsen C, Lindequist S. Early treatment ofairway pressure in very low-birth-weight infants. Acta Paediatr1993; 82: 193–7.

3. Roberton NRC. Does CPAP work when it really matters? ActaPaediatr 1993; 82: 206–7.

4. Vanpee M, Walfridsson-Schultz U, Katz-Salamon M, ZupancicJAF, Pursley DBJ. Resuscitation and Ventilation Strategies forExtremely Preterm Infants: A Comparison Study betweenBoston and Stockholm. Acta Paediatr 2007; 96: 10–16.

5. Jobe A. Ventilation strategies – Boston versus elsewhere –revisited. Acta Paediatr 2007; 96: 8–9.

6. Verder H. Nasal CPAP has become an indispensable part of theprimary treatment of newborns with RDS. Acta Paediatr 2007;96: 482–485.

C©2007 The Author/Journal Compilation C©2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2007 96, pp. 481–481 481