CPAP and the preterm infant: lessons from the COIN trial and other studies.

Bronchopulmonary dysplasia is associated with ventilation. Nasal continuous positive airway pressure (nCPAP) allows earlier weaning in ventilated infants. Starting nCPAP from shortly after birth to prevent ventilation has been questioned because it prevents an early use of surfactant. The efficacy of early surfactant was assessed in infants electively intubated, few having received antenatal steroids. Recent trials using nCPAP from birth in 25 to 28 week infants describe more customised strategies: in the COIN trial, 27-28 week infants breathing at birth benefit the most from nCPAP. Fewer infants received oxygen on day 28; they had fewer days of ventilation and no increase in morbidities despite having more pneumothoraces. The REVE trial suggests that intubation with early surfactant administration followed by nCPAP mostly benefits to 25-26 week infants. Thus, nCPAP is feasible from birth. The overall strategy should take into account infants' gestational age, maturation and behaviour in the delivery room.