Non-invasive versus invasive respiratory support in preterm

infants at birth: systematic review and meta-analysis

Georg M Schmölzer, consultant,1,2,3 Manoj Kumar, consultant,1,2 Gerhard
Pichler, consultant,1,2,3 Khalid Aziz, professor,1,2 Megan O’Reilly, postdoctoral
fellow,1,2 and Po-Yin Cheung, professor1,2
Author information Article notes Copyright and License information PMC Disclaimer
This article has been corrected. See BMJ. 2014; 348: g58.

Associated Data
Supplementary Materials

Go to:

Abstract

Objective To assess the role of nasal continuous positive airway

pressure (CPAP) initiated at birth for prevention of death and
bronchopulmonary dysplasia in very preterm infants.

Design Systematic review.

Data sources PubMed, Embase, the Cochrane Central Register of

Controlled Trials, and online Pediatric Academic Society abstracts from
the year of inception to June 2013.

Eligibility criteria for selecting studies Randomised controlled trials

evaluating the effect of nasal CPAP compared with intubation in preterm
infants born at less than 32 weeks’ gestation and presenting the
outcomes of either death or bronchopulmonary dysplasia, or both
(defined as the need for oxygen support or mechanical ventilation at 36
weeks corrected gestation), during hospital stay.

Results Four randomised controlled trials (2782 participants) met the

inclusion criteria, with 1296 infants in the nasal CPAP group and 1486 in
the intubation group. All the trials reported bronchopulmonary dysplasia
independently at 36 weeks corrected gestation, with borderline
significance in favour of the nasal CPAP group (relative risk 0.91, 95%
confidence interval 0.82 to 1.01, risk difference −0.03, 95% confidence
interval −0.07 to 0.01). No difference in death was observed (relative
risk 0.88, 0.68 to 1.14, risk difference −0.02, −0.04 to 0.01, respectively).
Pooled analysis showed a significant benefit for the combined outcome
of death or bronchopulmonary dysplasia, or both, at 36 weeks corrected
gestation for babies treated with nasal CPAP (relative risk 0.91, 0.84 to
0.99, risk difference −0.04, -0.07 to 0.00), number needed to treat of 25).

Conclusion One additional infant could survive to 36 weeks without

bronchopulmonary dysplasia for every 25 babies treated with nasal
CPAP in the delivery room rather than being intubated.
Go to:

Introduction

Despite recent advances in perinatal-neonatal care, there is a trend of

increased incidence of bronchopulmonary dysplasia among survivors of
prematurity.1 Most infants who develop bronchopulmonary dysplasia are
born prematurely, and 75% of affected babies weigh less than 1000 g at
birth.2 3 The risk of developing bronchopulmonary dysplasia increases
with decreasing birth weight, with reported incidence as high as 85% in
neonates weighing between 500 g and 699g, but only 5% in infants with
birth weights over 1500 g.2 3 In the most immature infants, even minimal
exposure to supplemental oxygen and mechanical ventilation could be
enough to contribute to bronchopulmonary dysplasia.2 3 This puts a
heavy burden on health resources because these infants are at risk of
frequent hospital readmissions in the first two years after birth and,
even as adolescents, have lung function abnormalities and persistent
respiratory symptoms.4 5

The lungs of very preterm infants are uniquely susceptible to injury

because they are structurally immature, deficient in surfactant, and not
supported by a stiff chest wall. Hence the lung of very preterm infants is
easily damaged by mechanical ventilation.6 To maintain functional
residual capacity and improve lung compliance and oxygenation, nasal
continuous positive airway pressure (CPAP) has been advocated at the
initiation of respiratory support.7 8 9 10 Observational studies in both the
era before the widespread use of antenatal steroids and after the
introduction of surfactant have documented an association between
lower rates of bronchopulmonary dysplasia and increased use of nasal
CPAP shortly after birth—that is, “primary” continuous positive airway
pressure as a means of avoiding endotracheal intubation and mechanical
ventilation.11 12 13 An observational study reported a lower rate of
bronchopulmonary dysplasia with much greater use of nasal CPAP in one
centre compared with seven other centres.11 Another study reported
higher bronchopulmonary dysplasia rates in two Boston centres when
compared with a single centre in New York (22% v 4%), with the higher
rates in Boston associated with more use of mechanical ventilation
(75% v 29%).12 Another retrospective study, of 261 preterm infants, that
compared intubation and ventilation with primary nasal CPAP reported
lower mortality and lower rates of administered surfactant,
bronchopulmonary dysplasia, and intraventricular haemorrhage in
infants who received nasal CPAP.13 In addition, a study compared rates of
bronchopulmonary dysplasia, intubation in the delivery room, and
mechanical ventilation for more than 24 hours in 14 tertiary level
neonatal intensive care units in northern Italy.14 Centres with high
delivery room intubation rates had higher rates of ventilation and
bronchopulmonary dysplasia.14 These studies prompted the launch of
large randomised controlled trials comparing nasal CPAP with
endotracheal intubation soon after birth. We reviewed the available
literature on the use of primary nasal CPAP soon after birth compared
with intubation and mechanical ventilation for the prevention of death
or bronchopulmonary dysplasia in very preterm infants.
Go to:

Methods
We searched PubMed, Embase, and the Cochrane Central Register of
Controlled Trials using a predefined algorithm (see supplementary file),
reviewed abstracts from annual meetings of the Pediatric Academic
Society (2000-12), and performed a manual search of references in
narrative and systematic reviews. Search terms included “infant”,
“newborn”, “resuscitation”, “continuous positive airway pressure”, and
“sustained inflation”.

Study selection

We included studies if they were randomised controlled trials, compared

nasal CPAP with endotracheal intubation as the primary mode of
respiratory support after birth in preterm populations at less than 32
weeks’ gestation, and presented the outcomes of either death or
bronchopulmonary dysplasia (defined as the need for oxygen support or
mechanical ventilation at 36 weeks corrected gestation) during hospital
stay. Our primary outcome measure was death or bronchopulmonary
dysplasia, or both, in a preterm population at less than 32 weeks’
gestation. Secondary outcomes included the need for any mechanical
ventilation during stay on a neonatal intensive care unit, treatment with
surfactant, pneumothorax, postnatal corticosteroid treatment,
intraventricular haemorrhage (grade III/IV or described as severe), any
necrotising enterocolitis, any patent ductus arteriosus or any patent
ductus arteriosus needing ligation, and any or severe retinopathy of
prematurity. The review team resolved any discrepancies in inclusion
through consensus.

Data extraction

Data were recorded using a standardised data collection form to record

study design and methodological characteristics, patient characteristics,
interventions, and outcomes, including the relative risks and 95%
confidence intervals. We also documented information on mode of
randomisation, allocation concealment, blinding, and intention to treat
analysis. Two investigators (GMS, MK) independently extracted data and
resolved discrepancies in consultation with another member of the
review team (PYC).

Assessment of methodological quality

We assessed the methodological quality of the included trials and

evaluated risk of bias using elements of the Cochrane Collaboration
tool.15 The domains used in the present systematic review pertained to
randomisation and allocation concealment (selection bias), blinding
(performance and detection bias), and adherence to the intention to
treat principle (attrition bias).

Statistical analysis

The principal summary measures were the weighted mean difference for
continuous outcomes and relative risk and absolute risk reduction for
dichotomous outcomes. For each trial we retrieved or calculated the
crude relative risk and absolute risk reduction estimates and
corresponding 95% confidence intervals for the assessed outcomes. We
explored heterogeneity using a χ2 test and measured the quantity of
heterogeneity with the I2 statistic.16 We used random effects models to
summarise relative risk and absolute risk reduction estimates.17 Analyses
were performed in RevMan version 5.2 (Cochrane Collaboration, 2013).
All P values are two tailed. Where the pooled estimates of relative risk
were statistically significant we calculated the numbers needed to treat
(NNT) for all outcomes. The study is reported according to the PRISMA
checklist.18
Go to:

Results

Figure 11 shows the flow of studies through the selection process. Our
initial search identified 65 citations of potentially eligible studies, of
which 50 were rejected based on a screening of the study title and
abstract. Of the remaining 15 studies that were assessed in full text, four
trials including 2780 infants7 8 9 10 fulfilled the inclusion criteria (table 1
1).). Table 22 presents an assessment of risk of bias for the included
studies. All described adequate randomisation. We assessed all the
studies as being at high risk of bias for blinding of participants and
caregivers, as it was not feasible to do so for the type of interventions
being compared; however, the studies did provide objective criteria for
defining their primary outcome and failure of treatment. All the studies
provided inhospital outcome data for the randomised participants, and
infants in all the studies were analysed by intention to treat. The nasal
CPAP and intubation groups were well matched; birth weight and
gestational age did not differ significantly (table 1). Other aspects of
respiratory treatment, including resuscitation devices used and criteria
for using endotracheal intubation and surfactant, were adequately
described in the studies and conformed to current international
guidelines. Overall, 518/1296 infants in the nasal CPAP group required
intubation within the first week after birth and 643/1296 infants in the
nasal CPAP group and 1402/1486 in the intubation group received
surfactant.

Fig 1 Flowchart for selection of eligible studies

Table 1
Characteristics of included randomised controlled studies. Values are means (standard
deviations) unless stated otherwise
 SUPPORT
Variables Morley (2008)7 (2010)8 Sandri (2010)10 Dunn (2011)9
Total No of 610 1316 208 648*
participants
Gestation (weeks) 250/7-286/7 240/7-276/7 250/7-286/7 weeks 260/7-296/7
CPAP group:
No in group 307 663 103 223
Birth weight (g) 964 (212) 834 (188) 967 (221) 1053 (252)
Gestational age 26.9 (1.0) 26.2 (1.1) 27.0 (1.0) 28.1 (1.1)
(weeks)
Intubation group:
No in group 303 653 105 425
Birth weight (g) 952 (217) 825 (198) 913 (200) 1040 (244)
Gestational age 26.9 (1.0) 26.2 (1.1) 27.0 (1.0) 28.0 (1.1)
(weeks)
Timing of After delivery Before delivery After delivery After delivery
randomisation
Stratification 250/7-266/7 and 240/7-256/7 and 250/7-266/7 and 260/7-276/7 and
(weeks) 270/7-286/7 260/7-276/7 270/7-286/7 280/7-296/7
Open in a separate window
CPAP=continuous positive airway pressure.

*Infants randomised to prophylactic surfactant group and intubate, surfactant, or extubate

group were combined in the intubation group (prophylactic surfactant group, gestational
age 28 (1.1 weeks) and birth weight 1040 g (244 g), intubate, surfactant, or extubate group
gestational age 28.1 (1.1) and birth weight 1066 (270 g)).

Table 2
Assessment of risk of bias in included studies

Blinding
Random of Selective
sequence Allocation Blinding of outcome Incomplet outcome
Yea generatio concealme participan assessme e outcome reportin
Study r n nt ts and staff nt data g
Morley et 200 Low Low High Unclear Low Low
al7 8
SUPPOR 201 Low Low High Unclear Low Low
T8 0
 Blinding
Random of Selective
sequence Allocation Blinding of outcome Incomplet outcome
Yea generatio concealme participan assessme e outcome reportin
Study r n nt ts and staff nt data g
Sandri et 201 Low Low High Unclear Low Low
al10 0
Dunn et 201 Low Low High Unclear Low Low
al9 1
Open in a separate window

Table 33 and figure 22 show the pooled results for our primary outcome.
All trials reported death or bronchopulmonary dysplasia independently
at 36 weeks corrected gestation. A reduction of bronchopulmonary
dysplasia occurred with borderline significance in favour of the nasal
CPAP group: relative risk 0.91 (95% confidence interval 0.82 to 1.01),
risk difference 0.03 (95% confidence interval −0.07 to 0.01, table 3, fig
2). Pooled analysis showed a significant benefit for the combined
outcome of death or bronchopulmonary dysplasia, or both, at 36 weeks
corrected gestation for babies treated with nasal CPAP: relative risk 0.91
(0.84 to 0.99), risk difference −0.04 (−0.07 to −0.00), NNT of 25 (fig 2).
Fig 2 Forest plot comparison of death or bronchopulmonary dysplasia (BPD), or both, at 36
weeks corrected gestation; death; and bronchopulmonary dysplasia at 36 weeks corrected
gestation. CPAP=continuous positive airway pressure

Table 3
Results of primary and secondary outcomes. Values are numbers of participants unless
stated otherwise

Relative
No of Nasal risk Risk Number
studies CPAP Intubation (95% difference needed
Variables (references) group group CI) (95% CI) to treat
Death at 36 47-10 145/1296 180/1486 0.88 −0.02
weeks corrected (0.68 to (−0.04 to
gestation 1.14) 0.01)
BPD at 36 47-10 383/1182 461/1354 0.91 −0.03
weeks corrected (0.82 to (−0.07 to
gestation 1.01) 0.01)
Death or BPD, 47-10 532/1296 641/1486 0.91 −0.04 25
or both (0.84 to (−0.07 to
0.99) −0.00)
Received any 47-10 839/1296 1441/1486 0.56 −0.34
mechanical (0.32 to (−0.68 to
ventilation 0.97) −0.01)
Surfactant 47-10 643/1296 1402/1486 0.40 −0.51
treatment (0.23 to (−0.79 to
0.70) −0.23)
Pneumothorax 47-10 86/1296 78/1486 1.26 0.01
(0.51 to (−0.04 to
3.09) 0.05)
Postnatal 37 8 10 97/1041 137/1024 0.73 −0.04
corticosteroid (0.49 to (−0.07 to
treatment 1.10) 0.00)
Intraventricular 47-10 133/1270 126/1445 1.1 (0.84 0.00
haemorrhage to 1.44) (−0.03 to
(grade III/IV) 0.03)
Any necrotising 47-10 122/1286 115/1469 1.19 0.01
enterocolitis (0.93 to (−0.01 to
1.52) 0.03)
Any patent 37 9 10 251/632 321/832 1.06 0.03
ductus arteriosus (0.87 to (−0.06 to
1.30) 0.11)
 Relative
No of Nasal risk Risk Number
studies CPAP Intubation (95% difference needed
Variables (references) group group CI) (95% CI) to treat
Patent ductus 27 10 50/410 60/408 0.83 −0.03
arteriosus (0.59 to (−0.07 to
needing ligation 1.17) 0.01)
Any retinopathy 38-10 278/602 336/771 1.05 0.01
of prematurity (0.80 to (−0.09 to
1.36) 0.11)
Severe 38-10 87/806 83/941 1.22 0.01
retinopathy of (0.71 to (−0.02 to
prematurity 2.08) 0.05)
Open in a separate window
CPAP=continuous positive airway pressure; BPD=bronchopulmonary dysplasia.

We identified significant heterogeneity for administered surfactant and

any mechanical ventilation and therefore these results must be
interpreted with caution. All trials assessed surfactant, with a significant
reduction in administered surfactant in the nasal CPAP group (relative
risk 0.40, 0.23 to 0.70, risk difference −0.51, −0.79 to −0.23, with 98%
heterogeneity). All trials assessed the need for any mechanical
ventilation, with a significant reduction in the nasal CPAP group (relative
risk 0.56, 0.32 to 0.97, risk difference −0.34, −0.68 to −0.01, with 99%
heterogeneity).

Other outcomes (including postnatal corticosteroid and patent ductus

arteriosus) were not significantly different between those treated with
nasal CPAP or with intubation (table 3). Subgroup analyses based on
gestational age were not possible because the results of individual
studies used different gestational ages for stratification. In addition, one
trial was stopped after recruitment reached 74% of the projected sample
size, owing to difficulties with enrolment.9

Long term outcomes have been reported recently for the SUPPORT trial
(Surfactant, Positive Pressure, and Pulse Oximetry Randomized
Trial),8 and Dunn et al are planning to report their long term outcomes at
two years corrected age.9 The SUPPORT trial did not show any difference
in death or neurodevelopmental impairment at 18 to 22 months
between groups.19
Go to:

Discussion

We identified four randomised controlled trials that compared nasal

CPAP with intubation,7 8 9 10 as they are somewhat difficult to undertake
during the emergent timeframe of neonatal resuscitation. Our meta-
analysis shows that one additional infant could survive to 36 weeks
without bronchopulmonary dysplasia for every 25 babies treated with
nasal continuous positive airway pressure (CPAP) in the delivery room
rather than being intubated and mechanically ventilated. In addition, the
reduction in bronchopulmonary dysplasia was of borderline significance.

However, caution should be exercised in generalising the results from

our review. All the studies required antenatal consent, preselecting more
stable pregnancies and lowering the observed incidence of acute or
serious antenatal and neonatal complications. In addition, 95% of the
infants included in our analysis received antenatal steroids.
Furthermore, none of the studies were blinded, raising the possibility of
bias influencing the outcomes if caregivers did not follow the trial
guidelines or changed subsequent management based on resuscitation
interventions. We did not conduct any formal tests for publication bias;
however, funnel plots (data not shown) revealed no obvious asymmetry.
Only one trial reported long term outcomes and reported no difference
between the nasal CPAP group and the intubation group.19

None of the trials enrolled infants of 23 weeks gestational age and only
one trial included infants of 24 weeks gestational age.8 These extremely
premature neonates represent a high risk group, with a high mortality
and a high need for early intubation in the delivery room. A further
confounder is the variation in how surfactant was administered between
the identified studies. The thresholds for intubation and surfactant
treatment varied from 40% to 60% oxygen, potentially influencing lung
injury acutely (that is, pneumothorax) or chronically as
bronchopulmonary dysplasia.

These studies were conducted when 21% oxygen was not recommended
as the initial oxygen concentration used for neonatal resuscitation. In
addition, the use of 100% oxygen in neonatal resuscitation has been
associated with increased oxidative stress and related pulmonary
injury.20 It will be interesting to examine if similar effects on mortality
and morbidity are observed when nasal CPAP is compared with
intubation and mechanical ventilation for extremely low birth weight
infants using 21-40% fractional inspired oxygen for initiating
resuscitation at birth. None the less, the rush to intubate and
mechanically ventilate at birth could be avoided with the increasing
knowledge of normal oxygen saturation levels in the first minutes after
birth.21 22 23

Despite these limitations, clinicians remain obliged to resuscitate

newborn infants on the basis of best available evidence, and researchers
should be encouraged to build on existing trials to deal with this
important problem. The studies included in this review prove that large
trials could be undertaken in the delivery room, with random allocation
of all eligible babies.24 Future trials should investigate different levels of
nasal CPAP and different strategies and thresholds for administering
surfactant and should ensure long term follow-up of neurodevelopment.
Waiver or deferral of consent might be considered as a means of
avoiding selection bias and improving generalisability.

Conclusions

Nasal CPAP initiated in the delivery room compared with intubation

reduces death or bronchopulmonary dysplasia in very preterm babies.
One additional infant could survive to 36 weeks without
bronchopulmonary dysplasia for every 25 babies treated with nasal
CPAP in the delivery room rather than being intubated and mechanically
ventilated.
 What is already known on this topic
 Most infants who develop bronchopulmonary dysplasia are born
prematurely, and most of these babies weigh less than 1000 g at birth
and are mechanically ventilated
 Providing nasal continuous positive airway pressure (CPAP) at birth has
been advocated to avoid lung injury and potentially lessen the risk of
bronchopulmonary dysplasia

What this study adds

 One additional infant could survive to 36 weeks without
bronchopulmonary dysplasia for every 25 babies treated with nasal
CPAP in the delivery room rather than being intubated
Go to:

Web Extra. Extra material supplied by the author

Search strategy

Click here for additional data file.(38K, pdf)

Go to:

Notes

Contributors: GMS, MK, and PYC conceived and designed the study. All
authors collected, assembled, analysed, and interpreted the data, drafted
the article, critically revised the article for important intellectual content,
and approved the final version of the article. GMS and PYC are the
guarantors. The sponsor of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of the report. All
authors were included in every step of the review and had full access to
all data. The corresponding author had final responsibility to submit for
publication.
Funding: This study received no specific funding.

Competing interests: All authors have completed the ICMJE uniform

disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: GMS had support
from Banting postdoctoral fellowship, Canadian Institutes of Health
Research and an Alberta Innovates—Health Solutions clinical fellowship
for the submitted work; no financial relationships with any organisations
that might have an interest in the submitted work in the previous three
years; no other relationships or activities that could appear to have
influenced the submitted work.

Ethical approval: Not required.

Data sharing: No additional data available.

Go to:

Notes

Cite this as: BMJ 2013;347:f5980

Go to:

References
1. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care
Med 2001;163:1723-9. [PubMed] [Google Scholar]
2. Baraldi E, Filippone M. Chronic lung disease after premature birth. N Engl J
Med 2007;357:1946-55. [PubMed] [Google Scholar]
3. Kinsella JP, Greenough A, Abman SH. Bronchopulmonary
dysplasia. Lancet 2006;367:1421-31. [PubMed] [Google Scholar]
4. Doyle LW, Faber B, Callanan C, Freezer N, Ford GW, Davis NM. Bronchopulmonary
dysplasia in very low birth weight subjects and lung function in late
adolescence. Pediatrics 2006;118:108-13. [PubMed] [Google Scholar]
5. Doyle LW, Anderson PJ. Long-term outcomes of bronchopulmonary
dysplasia. Semin Fetal Neonatal Med 2009;14:391-5. [PubMed] [Google Scholar]
6. Schmölzer GM, Te Pas AB, Davis PG, Morley CJ. Reducing lung injury during
neonatal resuscitation of preterm infants. J Pediatr 2008;153:741-5.
[PubMed] [Google Scholar]
7. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB. Nasal CPAP or
intubation at birth for very preterm infants. N Engl J Med 2008;358:700-8.
[PubMed] [Google Scholar]
8. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research
Network, Finer NN, Carlo WA, Walsh MC, Rich W, Gantz MG, Laptook AR, et al. Early
CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010;362:1970-
9. [PMC free article] [PubMed] [Google Scholar]
9. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, et al. Randomized
trial comparing 3 approaches to the initial respiratory management of preterm
neonates. Pediatrics 2011;128:e1069-76. [PubMed] [Google Scholar]
10. Sandri F, Plavka R, Ancora G, Simeoni U, Stranak Z, Martinelli S, et al.
Prophylactic or early selective surfactant combined with nCPAP in very preterm
infants. Pediatrics 2010;125:e1402-9. [PubMed] [Google Scholar]
11. Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB, et al. Is chronic
lung disease in low birth weight infants preventable? A survey of eight
centers. Pediatrics 1987;79:26-30. [PubMed] [Google Scholar]
12. Van Marter LJ, Allred EN, Pagano M, Sanocka U, Parad R, Moore M, et al. Do
clinical markers of barotrauma and oxygen toxicity explain interhospital variation in
rates of chronic lung disease? Pediatrics 2000;105:1194-201. [PubMed] [Google
Scholar]
13. Ammari A, Suri M, Milisavljevic V, Sahni R, Bateman D, Sanocka U, et al. Variables
associated with the early failure of nasal CPAP in very low birth weight infants. J
Pediatr 2005;147:341-7. [PubMed] [Google Scholar]
14. Gagliardi L, Bellù R, Lista G, Zanini R, and Network Neonatale Lombardo Study
Group. Do differences in delivery room intubation explain different rates of
bronchopulmonary dysplasia between hospitals? Arch Dis Child—Fetal Neonatal
Ed 2011;96:F30-5. [PubMed] [Google Scholar]
15. Higgins JPT, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The
Cochrane Collaboration’s tool for assessing risk of bias in randomised
trials. BMJ 2011;343:d5928-8. [PMC free article] [PubMed] [Google Scholar]
16. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat
Med 2002;21:1539-58. [PubMed] [Google Scholar]
17. Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in systematic reviews. Ann
Intern Med 1997;127:820-6. [PubMed] [Google Scholar]
18. Moher D, Tetzlaff J, Tricco AC, Sampson M, Altman DG. Epidemiology and
reporting characteristics of systematic reviews. PLoS Med 2007;4:e78. [PMC free
article] [PubMed] [Google Scholar]
19. Vaucher YE, Peralta-Carcelen M, Finer NN, Carlo WA, Gantz MG, Walsh MC, et al.
Neurodevelopmental outcomes in the early CPAP and pulse oximetry trial. N Engl J
Med 2012;367:2495-504. [PMC free article] [PubMed] [Google Scholar]
20. Vento M, Cheung P-Y, Aguar M. The first golden minutes of the extremely-low-
gestational-age neonate: a gentle approach. Neonatology 2009;95:286-98.
[PubMed] [Google Scholar]
21. Dawson JA, Kamlin COF, Vento M, Wong C, Cole TJ, Donath SM, et al. Defining the
reference range for oxygen saturation for infants after
birth. Pediatrics 2010;125:e1340-7. [PubMed] [Google Scholar]
22. Dawson JA, Vento M, Finer NN, Rich W, Saugstad OD, Morley CJ, et al. Managing
oxygen therapy during delivery room stabilization of preterm infants. J
Pediatr 2012;160:158-61. [PubMed] [Google Scholar]
23. Rabi Y, Yee W, Chen SY, Singhal N. Oxygen saturation trends immediately after
birth. J Pediatr 2006;148:590-4. [PubMed] [Google Scholar]
24. Davis PG, Tan A, O’Donnell CPF, Schulze A. Resuscitation of newborn infants with
100% oxygen or air: a systematic review and meta-analysis. Lancet 2004;364:1329-
33. [PubMed] [Google Scholar]
Analisa PICOT

P : Populasi / sampel penelitian dilakukan pada bayi lahir dengan UG < 32

minggu, dilakukan pada 2782 bayi yang lahir tahun 2013
I : Dilakukan pemantauan secara terkontrol Pada kelompok intervensi
penggunaan cpap ditemukan pada 1296 bayi, dan bayi dilakukan intubasi
sebanyak 1476. Pada usia gestasi 36 minggu ditemukan penurunan angka
kejadian BPD pada kelompok bayi yang menggunakan CPAP. Tidak ditemukan
banyak perbedaan terhadapangka kematian pada pemakai CPAP maupun
intubasi.
C : Hasil penelitian didapatkan, bahwa pada bayi dengan pemakaian
CPAP,ditemukan angka terjadi BPD menurun pada usia gestasi 36 minggu
dengan perbandingan 1 : 25 bayi memiliki outcome yang baik.
O : Hasil penelitian menemukan dalam 25 bayi yang dirawat dengan CPAP
terdapat 1 bayi yang terbebas dari bronkopulmonarii diplasia selama
perawatan disbanding dengan bayi yang terintubasi.
T : penelitian dilakukan selama tahun 2013