To Intubate or Not to Intubate at Birth, This Is Still the Question! Will Experimental Studies Give Us the Answer?: Commentary on the article by Polglase et al. on page 67

Rimensberger, Peter C

doi:10.1203/PDR.0b013e31818d84d7

Commentary
Published: January 2009

To Intubate or Not to Intubate at Birth, This Is Still the Question! Will Experimental Studies Give Us the Answer?: Commentary on the article by Polglase et al. on page 67

Peter C Rimensberger^1,1

Pediatric Research volume 65, pages 19–20 (2009)Cite this article

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Providing nasal CPAP (nCPAP) rather than intubating, has been identified as a potential better practice according to basic quality improvement criteria (1). In fact, over the last decade, many studies have suggested an association between the increased use of nCPAP and lower rates of intubation and/or lower rates of bronchopulmonary dysplasia (BPD) (2–5). However, due to the observational and/or retrospective character of these studies, it is difficult to know whether this association can be attributed to a changing delivery room practice, focused on early initiation of nCPAP, or some other factor(s).

To date, three randomized controlled trials, employing an appropriate study design, have tried to test the hypothesis that not intubating preterm babies with respiratory distress syndrome, at or soon after birth, would have a positive effect on outcome. A large scale multicenter trial conducted by the IFDAS (Infant Flow Driver and Surfactant) study group (6), with a four group design consisting of 1) early nCPAP with prophylactic surfactant, 2) early nCPAP ± rescue surfactant, 3) early intermittent positive pressure ventilation (IPPV) with prophylactic surfactant, and 4) early IPPV ± rescue surfactant treatment, failed to show any inter-group differences in the incidence of chronic lung disease. This study was never published after peer-review, which makes a careful and eventual nuanced interpretation of the results impossible. Why these authors never managed to publish this large clinical multicenter trial remains open, but one reason may be due to the inability of investigators to reproduce clinically the observed results from the controlled setting of a laboratory (7). A second study, a single center study by Kugelman et al. (8), could show decreased requirement for endotracheal ventilation with the early use of nCPAP in premature infants with RDS. This was associated with a decreased incidence of BPD. The third study, again a large sized multicenter study, the COIN (Continuous Positive Airway Pressure or Intubation at Birth) trial (9), failed to show that a “not to intubate” strategy in very preterm infants (25-to-28 wk' gestation at birth) would also reduce BPD. Even though the CPAP group in this study had an increased incidence of pneumothoraces, they had fewer days of ventilation, and fewer infants received oxygen at 28 d.

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Department of Pediatrics, University Hospital and University of Geneva, Geneva, CH-1211, Switzerland
Peter C Rimensberger & Peter C Rimensberger

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Rimensberger, P. To Intubate or Not to Intubate at Birth, This Is Still the Question! Will Experimental Studies Give Us the Answer?: Commentary on the article by Polglase et al. on page 67. Pediatr Res 65, 19–20 (2009). https://doi.org/10.1203/PDR.0b013e31818d84d7

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Received: 25 August 2008
Accepted: 10 September 2008
Issue date: January 2009
DOI: https://doi.org/10.1203/PDR.0b013e31818d84d7

To Intubate or Not to Intubate at Birth, This Is Still the Question! Will Experimental Studies Give Us the Answer?: Commentary on the article by Polglase et al. on page 67

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