Delivery Room Management

Several trials of delivery room management have investigated the relative benefits of intubating all the babies (and usually giving them all or most of them surfactant) or trying to maintain them on CPAP.

This table gives an outline of the methods (INSURE is INtubation SURfactant and immediate Extubation):

Trial ID
GA of subjects
Age of intubation, control group.
Initial Pressure of CPAP (CPAP group)
Indications for failure, CPAP group
Primary outcome
24-27 wk
In DR, surfactant within 1 hr
5 cmH2O
FiO2>0.5, CO2>65, hemodynamic instability
Death or BPD
25-28 wk
5 min, surfactant optional, according to local protocol
8 cmH2O
FiO2 >0.6, pH <7.25 with PCO2>60, multiple apneas
Death or BPD
640 (3 groups)
26-29 wk
5 to 15 min, immediate surfactant, with either INSURE (group2) or progressive wean (group1)
5 cmH2O (max 7)
FiO2 >0.4 option to intubate

>0.6 mandatory (or CO2 >65 or multiple apneas)

Death or BPD
25-28 wk
<30 min, INSURE
6 to 7 cmH2O
FiO2 >0.4, CO2>65 with pH<7.2 (multiple apneas)
Need for ventilation within the 1st 5 days of life

As for the results:

Support Study Group. Early CPAP versus surfactant in extremely preterm infants. The New England journal of medicine. 2010;362(21):1970-9. The SUPPORT trial . There was no difference in the primary outcome, survival without BPD, but some indication of less severe lung injury in the CPAP group

Morley CJ, et al. Nasal CPAP or intubation at birth for very preterm infants. The New England journal of medicine. 2008;358(7):700-8. The COIN trial.  There was no difference in survival without BPD, but there was somewhat less severe BPD in the CPAP group, and more pneumothoraces in the CPAP group.

Dunn MS, et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics. 2011;128(5):e1069-76. The VON DR management trial. Study was stopped early for declining enrollment. The CPAP group, and the INSURE group had better outcomes (death or BPD) than the intubation and ongoing ventilation group, but no significant differences.

Sandri F, et al. Prophylactic or Early Selective Surfactant Combined With nCPAP in Very Preterm Infants. Pediatrics. 2010;125(6):e1402-9.  The CURPAP trial. No differences were found in important outcomes, including the primary, survival without BPD.

I performed a meta-analysis of these trials, dividing them according to whether the comparison was with INSURE or with surfactant and traditional weaning.

Figure 3 CPAP

Which means that if you think you need to intubate a baby for surfactant, try to get them extubated again really fast.