CPAP failure in preterm infants: incidence, predictors and consequences

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1 CPAP failure in preterm infants: incidence, predictors and consequences SUPPLEMENTAL TEXT METHODS Study setting The Royal Hobart Hospital has an 11-bed combined Neonatal and Paediatric Intensive Care Unit within a general hospital, and the Royal Women s Hospital a -bed Neonatal Intensive Care Unit (NICU) within a women s hospital. Both have tertiary level neonatal intensive care facilities with a full range of therapeutic options for premature infants. Management of preterm infants at weeks gestation is similar in the two centres. Both units initially use CPAP by preference for infants with respiratory distress, using either the bubble CPAP system (Fisher & Paykel, East Tamaki, New Zealand) or a mechanical ventilator (Dräger Babylog 8 plus, Dräger Medical, Mount Waverley, Australia), in each case delivered with short binasal prongs (Hudson Respiratory Care, Temecula, USA). Early intubation for surfactant administration is not practised. Neither unit uses the high flow nasal cannula system for initial respiratory support. Starting pressure on CPAP is 5-7 cm H 2 O, with the pressure level then titrated according to oxygenation and work of breathing. Maximum sustained CPAP pressure is 8 cm H 2 O. FiO 2 is adjusted to maintain oxygen saturation (SpO 2 ) in the range of 88-92%. The maximum acceptable FiO 2 on CPAP in both units is

2 Infants exceeding the above CPAP and FiO 2 limits are intubated, and exogenous surfactant is administered soon after if clinically indicated. The INSURE approach (intubation, surfactant, extubation) is not practiced. Other indications for intubation are severe apnoea and protracted respiratory or metabolic acidosis unresponsive to treatment (ph <7.2 on repeated estimations). Caffeine is used in all infants < 29 weeks, and selectively at higher gestations. Infants with a haemodynamically significant patent ductus arteriosus are treated with prostaglandin inhibitors. Screening for IVH and retinopathy of prematurity (ROP) is done according to standard schedules.

3 Number A Gestation (weeks) Proportion B 67% 42% 63% 25% 19% 22% 1% 11% 1% 9% 8% 7% 6% 5% % 3% % 1% % Gestation (weeks) Supplemental Figure 1. Initial respiratory support by gestation Cumulative histograms showing respiratory therapy initiated at each gestational age (completed weeks). Panel A: raw values; panel B: proportions in relation to total number receiving respiratory support, with the CPAP failure rate in those commencing on CPAP indicated above each column. Black bars: intubated primarily; white bars: initial CPAP, successful; grey bars: initial CPAP, but failed and required intubation before 72 h.

4 Days A Days B Respiratory support Oxygen therapy Respiratory support Oxygen therapy Supplemental Figure 2. Respiratory support and oxygen therapy Box and whisker plots of duration of respiratory support and oxygen therapy in the CPAP groups. Panel A: weeks gestation; panel B: weeks gestation. White bars: initial CPAP, successful; grey bars: initial CPAP, failed. In each case, median value higher in infants failing CPAP, P<.1, Mann-Whitney test. At weeks, median duration of respiratory support was 5 days (IQR 11-6) in the CPAP-F group and 1 (3.6-32) days in the CPAP-S group; corresponding values for week infants were CPAP-F: 6.3 ( ); CPAP-S: 1.4 ( ).

5 Respiratory support first 24 h weeks weeks Total 132 (51 RHH, 81 RWH) 27 (97 RHH, 173 RWH 2 (148 RHH, 254 RWH) Intubated primarily Initial CPAP CPAP-S 36 (55%) 196 (85%) 232 (78%) CPAP-F 3 (45%) 35 (15%) 65 (22%) Supplemental Table 1. Respiratory support by gestation range Details of initial respiratory support in the first 24 hours, after exclusion of cases of prolonged membrane rupture (n=36) and congenital anomaly (n=9). CPAP-S: succeeded on CPAP; CPAP-F: failed CPAP and intubated in first 72 hours; RHH: Royal Hobart Hospital, RWH: Royal Women s Hospital.

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