1. CPAP versus Surfactant for the ELBW Infant The Argument for CPAP
Neil Finer
Director, Division of Neonatology
Professor of Pediatrics
UCSD Medical School

2. Evidence for Efficacy of CPAP
Gregory et al (NEJM 1971;284:1330) demonstrated that CPAP improved oxygenation in infants < 1500 gm with RDS
Rhodes et al (Pediatr 1973;52:17) reported increase survival with face mask CPAP
CPAP improves FRC and premature infants without adequate FRC are more likely to develop HMD (Upton et al, Arch Dis Child 1991;66:39)
The use of CPAP decreases mortality in the presurfactant era ( Ho et al Cochrane LibraryCLIB Issue #3 2002)

3. CPAP vs Mechanical Ventilation from Birth Beneficial Effects: Animal Studies
CPAP from birth in preterm lambs produces gas exchange similar to or better than mechanical ventilation for 72 hours (Null et al, PAS May 2004)
Preterm lambs treated with CPAP from birth at 2 hours had lungs with greater volumes and lesser neutrophils and hydrogen peroxide than lambs ventilated from birth ( Jobe et al, Ped Res 2002:52:387)

4. Evidence for Efficacy of CPAP: Last Pre-Surfactant Prospective Trial Han et al Early Human Dev 1987;15:21
Compared early CPAP ( up to 2hours after birth)
No maternal Antenatal Steroids
CPAP associated with worse oxygenation
There is no Post-Surfactant Antenatal Steroid Era prospective RCT comparing DR/Early Surfactant to Surfactant
Current Cochrane Review on Prophylactic CPAP concludes that a multicentered RCT comparing prophylactic CPAP with standardized care was needed!
(Subramanian et al Cochrane Library Issue4 2003)

5. Origins of Chronic Lung Disease
Review of number of units demonstrated that the unit which used least ventilation, allowed permissive hypercarbia and used initial Nasal CPAP had lowest BPD rates (Columbia)
This unit did not use muscle paralysis
Recently reported low BPD rate = 3/81, (4.7%)
50% survival without BPD for infants gm
Avery et al, Pediatr 1987:79:26

6. Evidence for Efficacy of CPAP: Population – European VLBW Cohort Studies
Jonsson et al (Acta Pediatr 1997;419:4) reported experience from Stockholm from 1988 – 1993 and use of higher PaCO2 51% treated with early CPAP < 30 min usually, only 1/3 required intubation
Almost all infants < 24 weeks required intubation
Gitterman et al (Eur J Pediatr 1997;156:384) reported that CPAP usually within 15 min of birth, reduced the need for intubation mortality, and LOS
Poets et al (Pediatr 1996;98:24) reported ventilation, without increased BPD, IVH or PVL in Germany from

7. Interhospital Variation of Chronic Lung Disease: Van Marter et al Pediatr 2000;105:1194
Compared early ventilatory practices for VLBW infants at 2 Boston Hospitals (341 infants) with Columbia (100 infants) born from 1991 to 1993
They evaluated use of mechanical ventilation for days 1-3, and 4-7
CLD ( O2 at 36 weeks) was 4% (Babies) vs 22%(Boston)
No differences in IVH, PVL, NEC, ROP, or mortality (9% vs 10%)

8. Other practices: Babies vs Boston
Interhospital Variation of Chronic Lung Disease: Van Marter et al Pediatr 2000;105:1194
Other practices: Babies vs Boston
Surfactant 10% vs 45% more often in CLD, 23% vs 65%
CPAP used primarily at Babies 63% vs 11%
Mechanical Ventilation as primary 29% vs 75%
Infants with CLD more likely to receive Mechanical Ventilation 77% vs 42%
Duration of Mechanical Ventilation 13 days vs 27 days
PaCO2 higher at Babies

9. Mechanical Ventilation and Chronic Lung Disease: Van Marter et al Pediatr 2000;105:1194
Overall Odds Ratio for the development of CLD was related to need for Mechanical Ventilation
on day of birth - OR = 13.4
Days OR = 9.6
Days OR = 6.3
Maximum PIP of > 25 cmH2O at birth, or > 20 cmH2O at 1 -3 days increases risk for CLD
Message: If you don’t intubate, the babies do better!!!
Oh by the way, this is all retrospective information!!!

10. Comparison of Boston and Stockholm: 10 Years Later Vanpee et al, Acta Paediatr 2007;96:10-16
Compared inborn infants < 28 weeks June
70 from Boston, 120 from Stockholm
Infants of equal severity by CRIB and SNAPPE-II!! ( Actually sicker in Stockholm)
Mortality identical at 17% and 18%

11. Comparison of Boston and Stockholm Vanpee et al, Acta Paediatr 2007;96:10-16
All infants in Boston intubated vs 44% in Stockholm
63% of CPAP started infants in Stockholm required subsequent intubation
22% of infants in Stockholm never required intubation!
47% of intubated infants in Stockholm were extubated in the first week vs 14% in Boston
Boston used higher MAPs (not from HFO!!)
28 days - identical

12. Comparison of Boston and Stockholm Vanpee et al, Acta Paediatr 2007;96:10-16
More infants on 36 weeks in Boston
@ 40 weeks more infants on Oxygen and BPD more severe in Boston!
More Moderate BPD in Boston = 40% vs 22%
Mech 7 days was the only predictor of moderate/severe BPD OR = 6.9

13. CPAP – Evidence: Ho 2002 (Cochrane)
Early application of CDP … in the treatment of RDS … reduces subsequent use of IPPV and thus may be useful in preventing the adverse effects of this treatment.
In preterm infants with RDS .. CDP either as CPAP or CNP is associated with…
… reduced respiratory failure
… reduced mortality
… increased rate of pneumothorax
…This is ancient pre ANS and Pre Surfactant data!!!

14. Prophylactic CPAP for the Preterm Infant P Subramaniam et al
Prophylactic CPAP for the Preterm Infant P Subramaniam et al. Cochrane Database of Systematic Reviews 2005, Issue 3.
Evaluated all studies to that time for infants < 32 weeks and/or < 1500 gm
Insufficient information to evaluate the effectiveness of prophylactic nasal CPAP in very preterm infants. Neither of the evaluated studies reviewed showed evidence of benefit in reducing the use of IPPV

15. Does CPAP prevent BPD?
This has never been proven in a published prospective trial.
There are many retrospective reports suggesting that early CPAP may be associated with less BPD

16. DR CPAP Trial Finer et al, Pediatrics 2004;114:651
Can you manage ELBW infants in DR with CPAP???
No infant could be intubated exclusively for surfactant in the DR
All Infants were 28 weeks or less
Intubated and received surfactant in NICU for minimal criteria:
FiO2 > 0.3 to maintain SaO2 > 90% or PaO2 > 45 torr
Arterial PaCO2 > with pH < 7.25
Apnea requiring bag and mask ventilation

17. Patient Population Means + Standard Deviation
CPAP N=55
Control N=48
Birth Weight
Gestation (weeks)
1 min 4
5 min 6
10 min

18. Percent Intubated in DR by Gestational Age
Gestational Age ( weeks)

19. Columbia Experience Ammari et al, J Pediatr 2005;147:341
Retrospectively evaluated 261 infants < 1240 gm at birth
June 1999 to July 2002
Surfactant used for intubated infants who required > 60% Oxygen, usually not given early
Failure = pH < 7.20 and PaCO2 > 65 torr, FiO2 > 0.6

20. Columbia Experience Ammari et al, J Pediatr 2005;147:341
Gestational Age
DR Intubation
DR CPAP
72 hours - CPAP Failure
CPAP Success
23-25 wks N = 87
31%
69%
38%
26-28 wks
N = 106 5%
95%
17%
78%
29-31 wks
N = 54 0%
100% 7%
93%

21. Columbia Experience Ammari et al, J Pediatr 2005;147:341
Birth Weight
DR Intubation
DR CPAP
72 Hours - CPAP Failure
CPAP Success
< 699 gm
N = 79
27%
73%
40%
33% gm
N = 90
11%
89%
18%
71%
gm N = 92 1%
99% 8%
92%

22. Nasal CPAP or Ventilation for Very Preterm Infants at Birth
Nasal CPAP or Ventilation for Very Preterm Infants at Birth. A Randomized Controlled Trial - COIN Trial Morley et al, PAS Toronto, May 2007
Infants born at 25+0 to 28+6 weeks
If breathing at 5 min and needing respiratory support randomized to immediate nasal CPAP at 8 cm H2O,without surfactant, or ventilation
610 infants were enrolled from April 1999 to March 2006, 307 randomized to CPAP and 303 to ventilation
33% were born at 25 or 26 weeks
Mean (SD) birthweight = 960 (215)g,
94% received antenatal steroids, 67% were delivered by CS.

23. COIN Trial - Results
Reduced Death or Oxygen 28 days OR (95% CI) (0.46 to 0.87, p=0.006).
No Change in 36 weeks
There was no significant difference in mortality.
Surfactant use was halved.
Statistically Significant increase in pneumothorax in the CPAP group (9% v 3%)(p<0.003)
CPAP in this trial was beneficial – Needs Longer term outcomes!!

24. SUPPORT Study - Hypothesis
We hypothesized that early CPAP with a limited ventilator strategy would reduce the incidence of death or survival with BPD at 36 weeks compared to early Surfactant Limited Ventilator strategy – Taken from Units that were using early CPAP and were accepting of higher PaCO2 values and higher FiO2 before intubation Early Surfactant defines as Surfactant within 1 hour of life

25. Methods – BPD Definitions
For the primary outcome, BPD was defined using the physiologic definition as the receipt of more than 30% oxygen at 36 weeks or the need for positive pressure support; or any oxygen dependence which was confirmed for infants requiring less than 30% oxygen at 36 weeks by attempted oxygen withdrawal.
Pre-specified secondary outcomes included the evaluation of BPD defined by the receipt of oxygen at 36 weeks.

26. Method – Patients
Inborn infants of 24 0/7 to 27 6/7 weeks gestation for whom a decision had been made to provide full resuscitation were eligible
Antenatal Parental consent was obtained
Enrollment from February 2005 to February 2009
Randomization was stratified by center and by gestational age (24 and 25 weeks; 26 and 27 weeks)

27. Methods: CPAP Arm Surfactant Delivery Room 5 cm H20 Intubation per NRP
If intubated, surfactant
Standard NRP
Intubation/ Surfactant
Considered if:
Fi02 > 0.5
PaCO2 > 65
Hemodynamic instability
Prior to 1 hour

28. Methods: Extubation Criteria Within 24 hrs of meeting all criteria
CPAP/Limited Ventilation
Surfactant
Fi02 < 0.50 and MAP < 10 cm
PaCO2 < 65
Vent rate < 20 bpm
Hemodynamically Stable
Fi02 < 0.35 and MAP < 8 cm
PaCO2 < 50
Ventilator rate < 20 bpm
Hemodynamically Stable

29. Results – Patient Population - N=1316
CPAP
(N = 663)
Surfactant
(N = 653)
Birthweight*
Gestational Age*
24 to 25 6/7ths (%) 43
26 to 27 6/7ths (%) 57
Race, White/Black/Hispanic (%)
38 / 38 / 21
36 / 42/ 19
Antenatal corticosteroids (%) 97 96
Multiple births (%) 27 24
*Mean +±Standard Deviation

30. Results – Primary Outcome
CPAP
N=663
Surfactant
N=653
Adjusted Relative Risk (95% CI)
Death or BPD (Physiologic)
47.8%
51.0%
0.95 (0.85, 1.05)
BPD - Physiologic
39.2%
40.6%
0.99 (0.87, 1.14)
Death by 36 weeks PMA
14.2%
17.5%
0.81 (0.63, 1.03)

31. Results – Other Pre-specified Outcomes
CPAP
N=663
Surfactant
N=653
Relative Risk or Difference in Means
BPD (O2 use at 36 wks)
40.2%
44.3%
0.94 (0.82, 1.06)
Death/BPD, 36 wks
48.7%
54.1%
0.91 (0.83, 1.01)
Severe ROP- survivors
13.1%
13.7%
0.94 (0.69, 1.28)
Any air leaks (14 days)
6.8%
7.4%
0.89 (0.6, 1.32)
Mechanical Vent Survivors (Days)
-3.0 (-5.6, -0.3)*
Alive and off MV at 7 days
55.3%
48.8%
1.14 (1.03, 1.25)*
Postnatal steroids for BPD
7.2%
13.2%
0.57 (0.41, 0.78)*
* = p<0.05

32. SUPPORT – Other Results
No differences in the incidence of:
PDA, PDA requiring surgery,
NEC, medical or surgical
Severe IVH/PVL
In the 24 to 25 weeks strata CPAP infants had a lower mortality than Surfactant infants:
CPAP 23.9% vs Surfactant 32.1%
Relative Risk difference 0.74 (0.57, 0.98)

33. Comparison with Previous Studies COIN Trial – NEJM 2008;358:700-8
Infants of 25 to 28wks, 5 minutes
610 infants vs 1316 infants
No protocol for surfactant, 8 cm H2O
Infants 26.9 wks vs 26.2 wks, BW = 960 vs 830gm
Death 36 wks – 33.9% vs 38.9%
SUPPORT = 48.7 vs 54.1
Air leaks – 9% vs 3% - higher in CPAP
SUPPORT = 6.8% vs 7.4% - No difference

34. Comparison with Previous Studies CURPAP Trial – Pediatr 2010;125:e 1402-9
208 inborn infants who were born at 25 to 28 weeks' gestation and were not intubated at birth were randomly assigned to prophylactic surfactant and extubation or nCPAP within 30 minutes of birth and selective surfactant.
Death and/or survival without oxygen at 28 days of life and 36 weeks' postmenstrual age and incidence of main morbidities of prematurity (secondary outcomes) were similar in the 2 groups.
Concluded that nCPAP should be started soon after birth in spontaneously breathing infants of 25 to 28 weeks' GA and early selective surfactant should be given once signs of respiratory distress have developed.

35. Comparison with Previous Studies VON Trial – Soll and Dunn et al PAS Vancouver 2010
648 infants from 26 to 29 6/7ths weeks enrolled at 27 centers.
Fewer infants in the NCPAP vs the PS group received surfactant (46 vs 99%) and were ventilated (45 vs 96%) during the first week of life.
No differences were seen in the primary outcome of death or CLD at 36 weeks postmenstrual age - 40% vs 53.1% (CPAP vs PS)
There were no statistically significant differences in mortality, other complications of prematurity or the composite outcome of death or major morbidity (severe ROP, CLD, PVL or severe IVH).

36. Comparison with Previous Studies Rojas et al – Pediatrics 2009;123:137-42
279 infants from 27 to 31 wks
Compared CPAP to intubation/surfactant and extubation within 1 hr of birth
Excluded 5 min Apgar < 2, intubated within 15 min, PROM > 3 wks
Air leaks higher in CPAP – 9% vs 2%
Early Intub/Surf had lesser BPD 49% vs 59% but only significant for wk infants

37. Early CPAP vs Early Surfactant – ELBW Infants
All Studies – Death or BPD ( by receipt of Oxygen)

38. Early CPAP vs Early Surfactant – ELBW Infants
Overall – 36 weeks

39. Early CPAP vs Early Surfactant – ELBW Infants
Early Early CPAP vs Early Surfactant – ELBW Infants
> 27 weeks – Death or BPD
Early CPAP vs Early Surfactant – ELBW Infants
27 weeks or Greater – Death or 36 weeks

40. SUMMARY of SUPPORT
There was no significant difference for primary outcome of death or BPD
More CPAP infants were alive and off mechanical ventilation by day 7 (p=0.011)
CPAP infants received less postnatal steroids for BPD (p<0.001) and required fewer vent days (p=0.03).
CPAP Infants 24 to 25 6/7 weeks had a significantly lower mortality rate while hospitalized (p<.01)
CPAP infants did not have increased morbidities

41. CPAP and Surfactant
Should very preterm infants be treated with elective intubation, surfactant and a period of ongoing MV or stabilized on nCPAP with later selective surfactant? – SUPPORT = NO
Should very preterm infants be treated with elective intubation, surfactant and rapid extubation to nCPAP or stablilized on nCPAP with later selective surfactant? No Obvious benefit over CPAP
If an infant is initially stabilized on nCPAP, what criteria should be used for selective surfactant treatment?

42. CPAP versus Early Intubation (+ Surf) and Ventilation
Study
Patients N
Death / BPD
CPAP
ETT
Other Findings with CPAP
COIN
25-28 wk
Vigorous
610
.80 ( )
46 %
Inc. air leak
Inc. mort (NS) wk
75% of intubated babies given surf
DRM/VON
26-29 wk
Liveborn
648
.83 ( )
52%
Dec. mort (NS)
Air leak similar
SUPPORT
24-27 wk
1316
.91 ( )
83%
Dec. mort wk
Early CPAP avoids intubation and has equivalent outcomes

43. Intubate, Surf and Extubate vs CPAP
Study
Patients N
Death / BPD MV
Other Findings
Rojas et al
27-31 wk
RDS
279
.86 ( )
.69 ( )
No diff in MV, BPD in lower GA group.
Very high BPD rate
CURPAP
25-28 wk
Vigorous
208
1.03 ( )
.95 ( )
Dec. air leak with nCPAP (NS).
Very low BPD rate
DRM/VON
26-29 wk
Liveborn
648
.94 ( )
1.14 ( )
ISX similar to CPAP
Air leak similar
Early CPAP is as Effective as INSURE for the very Preterm Infant

44. CONCLUSIONS
Early CPAP with a limited ventilator strategy for the extremely low birth weight infant is associated with decreased exposure to intubation and mechanical ventilation, decreased death in the most immature infants, without any increase in measured morbidities
Early CPAP yields outcomes as good as a strategy of Early Intubation+Surf+Extubation for infants < 28 weeks gestation

46. Not all ELBW infants need to be intubated!!
CPAP started at birth is a preferred intervention to Surfactant.

48. CPAP Versus Surfactant
There was once a boy named Mike
He was a clever and curious and hard not to like!
He believed that all small babies as soon as they were born
Should be given surfactant lest their families would mourn
He scoffed at early CPAP use, what folly is this he thought
Surfactant has stood the test of time, and for this he fought

49. So Mike held his beliefs and his surfactant stocks soared
But as the evidence for CPAP grew his ox was gored
Whenever he had the chance he protected his turf
“CPAP is Ok but don’t give up on the surf,
Their noses will be battered, and their bowels will perf”
Now Mike good fellow, these rantings can’t last
Use early CPAP, and put BPD in your past!

50. Rebuttal: Other Potential Benefits of Using CPAP and Avoiding Intubation
Avoid Intubation and associated pathophysiology
Avoid surfactant administration complications
Avoid volu/barotrauma associated with mechanical ventilation
Avoid hypocarbia which is usually the result of mechanical ventilation, and seen often after resuscitation
Allow premedication for intubation when done later

51. Neonatal Intubation: Physiologic Responses Kelly, M. A. and Finer, N
Neonatal Intubation: Physiologic Responses Kelly, M. A. and Finer, N. J Pediatr Aug; 105:303
All attempts are associated with fall in SaO2, HR, increase followed by decrease in BP, except in ELBW where BP falls very quickly
Laryngoscope in mouth triggers responses
Longer the attempt – worse are effects!!
All of these can be prevented or reduced with premedication with atropine, a muscle relaxant and a narcotic or anesthetic agent
Premedication is not a usual option for Delivery Room Intubation for surfactant!
Even for later intubation – most do NOT premedicate!!!

52. Limitations of Surfactant Studies
None of the definitive trials to show effectiveness for Surfactant used a control group that received early CPAP
For all trials the use of Antenatal steroids was variable and below current usage
Few ELBW infants especially < 750 gm at birth
Approach to ventilation was not controlled
Prophylactic Surfactant treats significant number of infants who don’t need it!!

53. Surfactant Administration requires Intubation Prophylactic Surfactant
Can use premedication outside of delivery room
Such premedication will reduce duration of the procedure, decreases associated adverse physiology, and increases success rates of all operators
In the DR no time and no ready vascular access.
This is one potential risk to early surfactant administration
In addition the ETT may be misplaced into Right main stem and result in unequal aeration and potentially increase air leaks

54. SUPPORT Results – Delivery Room
Variable
CPAP (N=663)
Surfactant (N=653)
Relative Risk for CPAP vs. Surfactant (95% CI)
Adjusted P- value
Apgar at 1 minute <3
23.3% (154/661)
25.6% (167/653)
0.92 (0.76, 1.11)
0.38
Apgar at 5 minutes <3
3.9% (26/663)
4.9% (32/653)
0.82 (0.5, 1.34)
0.43
PPV in the DR
65.7% (435/662)
92.9% (606/652)
0.71 (0.67, 0.75)
<0.0001
Intubated in DR
34.4% (227/660)
93.4% (609/652)
0.37 (0.34, 0.42)
DR intubation for resuscitation
32.6% (215/660)
27.0% (176/652)
1.21 (1.02, 1.43)
0.02
Surfactant in DR or NICU
67.1% (443/660)
98.9% (646/653)
0.67 (0.64, 0.71)
Epinephrine in DR
2.0% (13/660)
4.1% (27/653)
0.48 (0.25, 0.91)

55. Adverse Events during Bolus Surfactant Administration
Oxygen desaturations of %
Reflux of drug up the endotracheal tube
Bradycardia (associated with desaturations) or vagal with airway obstruction
Fluctuations in cerebral blood flow (decreased)
Fall in blood pressure
Rise in pC02
Reduction in cortical EEG voltage – Also seen with Intubation!
Extubation during manipulation of infant
Increased IVH ( Gleissner et al J Perinat Med. 2000; 28(2):

56. Surfactant Administration
ETCO2

57. Potential Benefits of Early CPAP Avoid Volutrauma and Hypocarbia Bjorklund et al, Pediatric Research ;42(3):
Five pairs of lamb siblings were delivered by cesarean section at d of gestation. One lamb in each pair was randomly selected to receive six manual inflations of mL/kg prior to surfactant Rx
Large breaths inhibited surfactant induced increase in compliance and lung volume, and caused more lung injury
“a few inflations with volumes that are probably harmless in other circumstances might, when forced into the surfactant-deficient lung immediately at birth, compromise the effect of subsequent surfactant rescue treatment.”

58. Use of CPAP in VLBW Infant: Apnea
CPAP shown to reduce apnea
Better for obstructive events
Probably preventing airway obstruction which is common in the very preterm infant
Often the cause of failure to successfully/easily bag some VLBW infants following a severe apneic spell!
Apnea commonest cause of failure of extubation!

59. Effect of CPAP on Incidence of Apnea60 50
(p<0.02) 40
APNEIC EPISODES / 12 HOURS 30 20 10
BEFORE
CPAP
DURING
CPAP
Kattwinkel 1975

60. Effect of CPAP on Central, Obstructive and Mixed Apnea ≥ 10 sec8
Central
Obstructive
Mixed 6
No. of Apneic Episodes
(mean ± SE) 4 2 On
Off On On
Off On On
Off On
CPAP (4 cm H2O)
Miller et al, J Pediatr 1985

61. Nasal CPAP for Neonatal Apnea
Decreases upper airway resistance
Increases in FRC
Improves oxygenation
? Stimulation of upper airway receptors

62. CPAP vs Nasal Synchronous Ventilation Kugelman et al, J Pediatr 2007: 150:521
We have supported babies who were intubated using CPAP following extubation
The best method of preventing such infants need for re-intubation is to provide them with breaths during the CPAP
That means you give them a ventilator breath through the CPAP prongs.
Usually such breaths are low pressure and usually well tolerated
Now there is a study evaluated this technique before intubation!!

63. CPAP vs Nasal Synchronous Ventilation
Kugelman et al, J Pediatr 2007: 150:521

64. Nasal Intermittent PPV Kishore et al Acta Paediatrica. 2009; 98(9):1412
76 neonates were enrolled (37 in 'early-NIPPV' and 39 in 'early-CPAP' groups).
Failure rate was less with 'early-NIPPV' versus 'early-CPAP'[13.5% vs. 35.9%, respectively, RR 0.38 (95% CI ), p = 0.024].
Need for intubation and mechanical ventilation by 7 days (18.9% vs. 41%, p = 0.036) was less with NIPPV.
Failure rate with NIPPV was less in the subgroups of subjects born at weeks (p = 0.023) and who did not receive surfactant (p = 0.018).

65. Mechanical Ventilation and Chronic Lung Disease: Serenius et al Acta Paediatrica. 2004; 93(8):
Other studies have reported association between duration of ventilation and BPD/CLD
BPD was associated with duration of mechanical ventilation (OR 2.71 per 1-wk increment in duration; 95% CI )
Other morbidities associated with ventilation
Severe IVH or PVL was associated with duration of mechanical ventilation (OR 1.53 per 1-wk increment in duration; 95% CI )

66. CPAP Use and Hypo/Hypercarbia
Does the use of CPAP lead to elevated PaCO2?
This has been partially evaluated
It would appear the CPAP treated infants in the DR have a transient period of hypercarbia which then resolves.
CPAP use avoids hypocarbia which may be the greater risk for brain injury and is seen in up to 1/4 of infants intubated in DR as is hyperoxia! (Tracy et al Archives of Disease in Childhood. 2004; 89:F84)

67. CPAP and PaCO2 Nugyen et al, Pediatr 2003;112 e208-e211
Compared ELBW infants treated with CPAP compared to those were intubated < 48hrs and > 48 hrs
Infants treated with CPAP alone had lower PaCO2s
Higher values seen in infants who required prolonged ventilation probably reflecting more severe lung disorders

68. Average daily PCO2 during the first week of life
Comparing Infants treated with CPAP vs Ventilated
CPAP
Intubated < 48hrs
Intubated > 48 hrs
Nguyen, A. T. et al. Pediatrics 2003;112:e208-e211
Copyright ©2003 American Academy of Pediatrics

69. Average daily maximum PCO2 levels for 3 groups
Comparing Infants treated with CPAP vs Ventilated
CPAP
Intubated < 48hrs
Intubated > 48 hrs
Nguyen, A. T. et al. Pediatrics 2003;112:e208-e211
Copyright ©2003 American Academy of Pediatrics

70. CPAP Physiologic Effects May Offset Surfactant Benefit!!
Decreases the work of breathing,
Establishes and maintain an adequate functional residual capacity,
Stabilizes air space, and promotes the release of surfactant stores.
Avoiding endotracheal intubation is of benefit for mucociliary transport and humidification of inspired air, as well as decreasing the risk of airway damage and secondary infection and the occurrence of lung barotrauma and volutrauma secondary to MV
Decreases apnea

71. CPAP Versus Surfactant
Now the truth be told about Mike
He is a clever and curious little tyke
He truly believes that there is no treatment so great
That it should be accepted before we have this debate
He put his money on the line and led a large trial
That produced evidence based on facts, because that is his style!!