Is it safer to intubate premature infants in the delivery room?

OBJECTIVES: Early nasal continuous positive airway pressure (ENCPAP) has recently emerged in neonatal units as an acceptable alternative to routine intubation and mandatory ventilation. The risks and benefits of ENCPAP have yet to be established. In this study, we aimed to examine variables that influenced the decision to initiate ENCPAP in the delivery room (DR). We also explored potential harmful effects of early intubation and examined whether unsuccessful ENCPAP attempts might subject infants to any unforeseen morbidity.
METHODS: All inborn very low birth weight (VLBW) infants admitted to the NICU since the implementation of the ENCPAP policy were included in this retrospective study. Infants were stratified initially into 2 cohorts according to whether they were intubated in the DR or began ENCPAP. Infants were then stratified into 4 groups according to the respiratory management during their first week of life. Infants in group 1 were supported with ENCPAP in the DR and continued to receive continuous positive airway pressure (CPAP) at least for the entire first week. Infants in group 2 began ENCPAP treatment in the DR but required intubation during the first week of life. Infants in group 3 were intubated in the DR but transitioned successfully to CPAP within the first 48 hours and were treated with CPAP for the first week of life or longer. Infants in group 4 were intubated in the DR and treated with intermittent mandatory ventilation for >48 hours. Univariate analyses compared different groups with the Wilcoxon nonparametric test, Kruskal-Wallis test, and analysis of variance. A multivariate regression model adjusted for differences in birth weights (BWs), gestational ages (GAs), race, and Apgar scores between the groups.
RESULTS: A total of 234 VLBW infants (weight of <1500 g) were admitted to the NICU during the period from August 1997 to December 2003. The mean BW was 977.1 +/- 305.8 g, and the mean GA was 27.7 +/- 2.7 weeks. The overall mortality rate was 11.1%, and the incidence of bronchopulmonary dysplasia among survivors was 17.4%. ENCPAP was implemented successfully in the DR for 151 (64.5%) infants, whereas 83 (35.5%) infants required intubation. Infants who required intubation had significantly lower GAs, BWs, and 1-minute Apgar scores. The use of ENCPAP in the DR increased significantly over time. The chance of successful maintenance with ENCPAP for >48 hours was not demonstrable at <24 weeks of gestation (10% success). Use of ENCPAP improved significantly by 25 weeks of gestation (45% success). Infants in group 1 required a shorter duration of oxygen use than did infants in group 3 (7.9 +/- 18.3 vs 39 +/- 32.7 days; regression coefficient [b] = 19 +/- 5.3). None of the infants in group 1 developed intraventricular hemorrhage of grade III or IV or retinopathy of prematurity of stage 3 or 4. Infants in group 3 did not show improved outcomes, compared with group 1. Compared with group 4, infants in group 2 had a higher incidence of necrotizing enterocolitis (15.6% vs 7.3%; b = 2.5 +/- 1.2).
CONCLUSIONS: The success of ENCPAP improved with increased GA and with staff experience over time. Infants treated successfully with ENCPAP were unlikely to develop intraventricular hemorrhage of grade III or IV. Infants who experienced ENCPAP failure were at increased risk for the development of necrotizing enterocolitis. Infants who were intubated briefly in the DR were at increased risk for prolonged oxygen requirement. An individualized approach should be considered for respiratory support of VLBW infants.