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Prophylactic sustained lung inflation followed by early CPAP vs. early CPAP at birth in extreme preterm neonates

The protection of preterm lungs should start immediately after birth, and the current trial is a much awaited research in this direction. This study (1) evaluates the role of application of prophylactic sustained lung inflation (SLI) immediately after birth as a lung protective strategy in decreasing the need of mechanical ventilation (MV) in first 72 hours of life and in preventing bronchopulmonary dysplasia (BPD) among extreme preterm infants. BPD is a multifactorial disease, and the advantage of SLI over intermittent MV in terms of improving functional residual capacity (2,3) forms the basis of this trial. The application of SLI immediately after birth is a new strategy which was first evaluated by Lindner et al. in 1999 (4). Two additional studies showed beneficial effects of SLI; however, one was an observational study (5) and the other did not use positive end expiratory pressure (6). The current randomised trial has used nCPAP immediately after birth in the control group and in the intervention group following SLI, thus overcoming the disadvantage of the previous trial. The investigators elucidated eligibility and exclusion criteria. The actual time of taking consent (antenatal or immediately after birth) is not clear. There was appropriate generation of the randomisation sequence and allocation concealment. Although the researchers who decided to start MV and those assessing the study end points were blinded to the intervention however, the caregivers were not blinded which could have led to performance bias. Given the paucity of the literature, the amount and duration of pressure chosen for providing SLI seem appropriate. Authors have set the SpO2 targets at 88–95% against the currently recommended targets of 91–95%. The sample size was calculated a priori, and the outcomes were clearly defined. All randomised subjects completed the trial as per protocol, and all predefined outcomes were reported. Authors have used intention-totreat principle. This study has shown that the application of prophylactic SLI followed by nCPAP in the delivery room decreased the need for MV in the first 72 hours of life in extreme preterm infants. However, there is no effect on the robust clinical outcomes such as death and/or BPD. Additionally, there is concern of a trend towards increased incidence of pneumothorax and interstitial emphysema, which may be related to the pressure and duration used in SLI. Moreover, there is no statistically significant difference in need and duration of any respiratory support. Although the trial has not resulted in reduction in BPD or death, the reduction in need of MV in first 72 hours may be beneficial in resource-restricted settings where the availability of MV is limited. Given these findings, the routine application of SLI at birth cannot be recommended in extreme preterm infants. More trials are required across different settings and gestations to establish its efficacy. Given the risk of air leak syndromes, future trials also need to establish the optimal pressure and duration of SLI. Moreover, the data regarding the neurodevelopmental outcome need to be generated to establish its long-term safety.