Issue 11 – April 2021

The 2010 update of the Neonatal Resuscitation Program (NRP) guidelines added consideration of continuous positive airway pressure (CPAP) for spontaneously breathing infants with labored breathing or hypoxia in the delivery room.¹ We examined use of nasal CPAP during initial resuscitation since the Neonatal Resuscitation guideline change.

We evaluated 427,622 infants born at 501-1500 grams or 22-29 weeks gestational age at Vermont Oxford Network (VON) member centers worldwide who required any initial resuscitation defined as surfactant therapy, endotracheal intubation, laryngeal mask airway placement, ventilatory support (including CPAP, nasal ventilation, bag-mask ventilation, or mechanical ventilation), epinephrine, or chest compressions.

Rates of nasal CPAP during initial resuscitation increased from 35% of infants in 2011 to 62% of infants in 2019. Rates of CPAP increased over time for gestational ages of at least 23 weeks and were highest for infants born at older gestational ages.

The care received in the critical transition from in utero to ex utero environments is guided by the NRP algorithm. High quality evidence from four randomized controlled trials and one meta-analysis showed a reduction in the composite outcome of death or bronchopulmonary dysplasia for infants ≤ 29 weeks gestational age with respiratory distress when treatment was started with CPAP compared with intubation and ventilation, aligning with the 2010 NRP update.^2-7

Following this change, the worldwide VON neonatal community has significantly increased delivery room CPAP use for infants 23-29 weeks’ gestation. The quality gap that remains — the proportion of spontaneously breathing infants with heart rate > 100 beats/minute that are intubated without first receiving a trial of CPAP support — is yet to be defined by our VON community of practice.

NRP emphasizes team-based training^8-9 and communication. This is necessary but not sufficient to ensure a high-quality critical transition. As we seek to further understand and close this quality gap in delivery room care, we must ensure our approach honors a health equity agenda, is in partnership with families, and utilizes robust quality improvement methodology so that we can all learn and improve together.

1. American Academy of Pediatrics and American Heart Association. NRP Neonatal Resuscitation Handbook 6th Edition. https://ebooks.aappublications.org/content/nrp-neonatal-resuscitation-textbook-6th-edition-english-version
2. Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2020; doi: 10.1542/peds.2020-038505E
3. Schmölzer GM, Kumar M, Pichler G, Aziz K, O’Reilly M, Cheung PY. Non-invasive versusinvasive respiratory supportin preterm infants at birth:systematic review and meta-analysis. BMJ. 2013;347:f5980. doi: 10.1136/bmj.f5980
4. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, Ferrelli K, O’Conor J, Soll RF; Vermont Oxford Network DRM Study Group. Randomized trialcomparing 3 approachesto the initialrespiratorymanagementof preterm neonates. Pediatrics. 2011;128:e1069–e1076. doi: 10.1542/peds.2010-3848
5. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med. 2008;358:700–708. doi: 10.1056/NEJMoa072788
6. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal ResearchNetwork. Early CPAP versussurfactantin extremelypreterm infants. N Engl J Med. 2010;362:1970–1979. doi: 10.1056/NEJMoa0911783
7. Sandri F, Plavka R, Ancora G, Simeoni U, Stranak Z, Martinelli S, Mosca F, Nona J, Thomson M, Verder H, Fabbri L, Halliday H; CURPAP Study Group. Prophylactic or early selective surfactant combined with nCPAP in very preterm infants. Pediatrics. 2010;125:e1402–e1409. doi: 10.1542/peds.2009-2131
8. Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, Sexton JB, Tyson JE, Helmreich RL. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. J Perinatol. 2007 Jul;27(7):409-14. doi: 10.1038/sj.jp.7211771. Epub 2007 Jun 7. PMID: 17538634.
9. Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics. 2010 Mar;125(3):539-46. doi: 10.1542/peds.2009-1635. Epub 2010 Feb 15. PMID: 20156896.

This report is made possible by Vermont Oxford Network members who voluntarily contribute data in a global effort to improve the care of high-risk newborns. VON members can view center-specific data by logging on to Nightingale and benchmark against this NICU by the Numbers report.

Editor: Erika Edwards, PhD, MPH

Analyst: Lucy Greenberg, MS

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