Decreasing delivery room CPAP-associated pneumothorax at ≥35-week gestational age

Abstract

We previously reported an increase in pneumothorax after implementing delivery room (DR) continuous positive airway pressure (CPAP) for labored breathing or persistent cyanosis in ≥35-week gestational age (GA) neonates unexposed to DR-positive pressure ventilation (DR-PPV). We hypothesized that pneumothorax would decrease after de-implementing DR-CPAP in those unexposed to DR-PPV or DR-O 2 supplementation (DR-PPV/O 2 ). STUDY DESIGN: In a retrospective cohort excluding DR-PPV the primary outcome was DR-CPAP-related pneumothorax (1st chest radiogram, 1st day of life). In a subgroup treated by the resuscitation team and admitted to the NICU, the primary outcome was DR-CPAP-associated pneumothorax (1st radiogram, no prior PPV) without DR-PPV/O 2 . RESULTS: In the full cohort, occurrence of DR-CPAP-related pneumothorax decreased after the intervention (11.0% vs 6.0%, P < 0.001). In the subgroup, occurrence of DR-CPAP-associated pneumothorax decreased after the intervention (1.4% vs. 0.06%, P < 0.001). CONCLUSION: The occurrence of CPAP-associated pneumothorax decreased after avoiding DR-CPAP in ≥35-week GA neonates without DR-PPV/O 2 .

The Feasibility and Impact of a Postresuscitation Care Protocol in the Well Baby Nursery

“…Emerging research has yielded conflicting results with DR CPAP associated with both an increase and decrease in NICU admission and need for respiratory support 15 . While DR CPAP may be considered a less aggressive form of resuscitation than PPV, there are increasing concerns about associated morbidities 2,7,9 . Studies in the United States and internationally have shown an increase in DR CPAP in term infants 2,16 , most dramatically from 1.7% to 11.1% 3 .…”

“…While DR CPAP may be considered a less aggressive form of resuscitation than PPV, there are increasing concerns about associated morbidities 2,7,9 . Studies in the United States and internationally have shown an increase in DR CPAP in term infants 2,16 , most dramatically from 1.7% to 11.1% 3 . Associated with this increase in DR CPAP has been an increase in pneumothoraces with > 4 times the odds of pneumothorax in late preterm and term infants 3,16 who received this intervention.…”

“…The use of DR CPAP has increased in late preterm and term infants. Recent reports indicate ~2-11% of late preterm and term infants receive DR CPAP 2,3 . The management of infants continuing to experience respiratory distress or other signs of instability after DR resuscitation is well delineated, admission to a neonatal intensive care unit (NICU) or special care setting.…”

“…The importance of developing a better knowledge of the risk of complications associated with DR resuscitation, particularly DR CPAP, has been explored in recent studies and editorials 2,3,6,7,9 . In a single center study, ~3.3% of WBN admissions received CPAP and/or PPV 6 .…”

Incidence of ultrasonographic signs of pneumothorax in asymptomatic neonates

“…Some studies suggest that the administration of intermittent positive pressure ventilation (IPPV) during resuscitation maneuvers at birth or the application of continuous positive airway pressure (CPAP) in newborns with respiratory distress are risk factors for the development of pneumothorax. [6][7][8] However, often it is not possible to determine if the pneumothorax was present before CPAP initiation. Newborns with spontaneous pneumothorax at birth usually present symptoms of respiratory distress, although if the air leak is small it can go unnoticed on chest X-rays and if the newborn remains asymptomatic.…”