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Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

BMJ 2013; 347 doi: (Published 17 October 2013) Cite this as: BMJ 2013;347:f5980

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  1. Georg M Schmölzer, consultant123,
  2. Manoj Kumar, consultant12,
  3. Gerhard Pichler, consultant123,
  4. Khalid Aziz, professor12,
  5. Megan O’Reilly, postdoctoral fellow12,
  6. Po-Yin Cheung, professor12
  1. 1Department of Pediatrics, University of Alberta, Edmonton, Canada
  2. 2Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
  3. 3Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
  1. Correspondence to: G M Schmölzer georg.schmoelzer{at}
  • Accepted 16 September 2013


Objective To assess the role of nasal continuous positive airway pressure (CPAP) initiated at birth for prevention of death and bronchopulmonary dysplasia in very preterm infants.

Design Systematic review.

Data sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and online Pediatric Academic Society abstracts from the year of inception to June 2013.

Eligibility criteria for selecting studies Randomised controlled trials evaluating the effect of nasal CPAP compared with intubation in preterm infants born at less than 32 weeks’ gestation and presenting the outcomes of either death or bronchopulmonary dysplasia, or both (defined as the need for oxygen support or mechanical ventilation at 36 weeks corrected gestation), during hospital stay.

Results Four randomised controlled trials (2782 participants) met the inclusion criteria, with 1296 infants in the nasal CPAP group and 1486 in the intubation group. All the trials reported bronchopulmonary dysplasia independently at 36 weeks corrected gestation, with borderline significance in favour of the nasal CPAP group (relative risk 0.91, 95% confidence interval 0.82 to 1.01, risk difference −0.03, 95% confidence interval −0.07 to 0.01). No difference in death was observed (relative risk 0.88, 0.68 to 1.14, risk difference −0.02, −0.04 to 0.01, respectively). Pooled analysis showed a significant benefit for the combined outcome of death or bronchopulmonary dysplasia, or both, at 36 weeks corrected gestation for babies treated with nasal CPAP (relative risk 0.91, 0.84 to 0.99, risk difference −0.04, -0.07 to 0.00), number needed to treat of 25).

Conclusion One additional infant could survive to 36 weeks without bronchopulmonary dysplasia for every 25 babies treated with nasal CPAP in the delivery room rather than being intubated.


  • Contributors: GMS, MK, and PYC conceived and designed the study. All authors collected, assembled, analysed, and interpreted the data, drafted the article, critically revised the article for important intellectual content, and approved the final version of the article. GMS and PYC are the guarantors. The sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors were included in every step of the review and had full access to all data. The corresponding author had final responsibility to submit for publication.

  • Funding: This study received no specific funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: GMS had support from Banting postdoctoral fellowship, Canadian Institutes of Health Research and an Alberta Innovates—Health Solutions clinical fellowship for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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