Delivery Room Continuous Positive Airway Pressure and ...

Delivery Room Continuous PositiveAirway Pressure and PneumothoraxWilliam Smithhart, MD,a Myra H. Wyckoff, MD,a Vishal Kapadia, MD,a Mambarambath Jaleel, MD,a

Venkatakrishna Kakkilaya, MD,a L. Steven Brown, MS,b David B. Nelson, MD,c Luc P. Brion, MDa

abstractBACKGROUND: In 2011, the Neonatal Resuscitation Program (NRP) added consideration ofcontinuous positive airway pressure (CPAP) for spontaneously breathing infants with laboredbreathing or hypoxia in the delivery room (DR). The objective of this study was to determine ifDR-CPAP is associated with symptomatic pneumothorax in infants 35 to 42 weeks’gestational age.

METHODS: We included (1) a retrospective birth cohort study of neonates born between 2001and 2015 and (2) a nested cohort of those born between 2005 and 2015 who hada resuscitation call leading to admission to the NICU and did not receive positive-pressureventilation.

RESULTS: In the birth cohort (n = 200 381), pneumothorax increased after implementation of the2011 NRP from 0.4% to 0.6% (P , .05). In the nested cohort (n = 6913), DR-CPAP increasedlinearly over time (r = 0.71; P = .01). Administration of DR-CPAP was associated withpneumothorax (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 4.4–6.8); the OR was higher(P , .001) in infants receiving 21% oxygen (OR: 8.5; 95% CI: 5.9–12.3; P , .001) than inthose receiving oxygen supplementation (OR: 3.5; 95% CI: 2.5–5.0; P , .001). Among thosewith DR-CPAP, pneumothorax increased with gestational age and decreased with oxygenadministration.

CONCLUSIONS: The use of DR-CPAP is associated with increased odds of pneumothorax in late-preterm and term infants, especially in those who do not receive oxygen in the DR. Thesefindings could be used to clarify NRP guidelines regarding DR-CPAP in late-preterm and terminfants.

WHAT’S KNOWN ON THIS SUBJECT: Continuouspositive airway pressure (CPAP) is a risk factor forpneumothorax. New Neonatal Resuscitation Programguidelines included CPAP as a possible correctivemeasure for spontaneously breathing infants whohave labored breathing or persistent cyanosis.

WHAT THIS STUDY ADDS: Among late-preterm andterm infants, pneumothorax increased afterimplementation of the new Neonatal ResuscitationProgram guidelines. Delivery room CPAP wasassociated with pneumothorax. The odds ratio washigher in infants receiving 21% oxygen than in thosereceiving oxygen supplementation.

To cite: Smithhart W, Wyckoff MH, Kapadia V, et al.Delivery Room Continuous Positive Airway Pressure andPneumothorax. Pediatrics. 2019;144(3):e20190756

aDivision of Neonatal-Perinatal Medicine, Department of Pediatrics and cDivision of Maternal-Fetal Medicine,Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, Texas; and bParkland Healthand Hospital System, Dallas, Texas

Dr Smithhart conceptualized and designed the study, merged the spreadsheets of the 2 databases,and wrote the first draft of the manuscript; Drs Wyckoff, Jaleel, Kapadia, Nelson, and Kakkilayaconceptualized and designed the study; Mr Brown conducted statistical analyses; Dr Brionconceptualized and designed the study and conducted statistical analyses; and all authorsparticipated in the interpretation of the data, critically reviewed the revisions, approved the finalmanuscript as submitted, and agree to be accountable for all aspects of the work.

DOI: https://doi.org/10.1542/peds.2019-0756

Accepted for publication May 28, 2019

Address correspondence to Luc P. Brion, MD, Division of Neonatal-Perinatal Medicine, Department ofPediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, STOP 9063,Dallas, TX 75390-9063. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

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The use of delivery room (DR)continuous positive airway pressure(CPAP) has increased in preterminfants in recent years,1 likelybecause of lower risk of the combinedoutcome of death orbronchopulmonary dysplasia, ascompared with DR endotrachealintubation.2,3 DR intubationdecreased in preterm infants atParkland Health and Hospital System(PHHS) as well,4 coinciding withparticipation (2005–2009) in theSurfactant, Positive Pressure, andOxygenation Randomized Trial(SUPPORT), in which researcherscompared DR intubation to DR-CPAP.5 New guidelines werepublished in 2010 and implementedby the Neonatal ResuscitationProgram (NRP) in 2011, whichincluded CPAP as a possiblecorrective measure for spontaneouslybreathing infants without apnea,gasping, or heart rate ,100 beats perminute who have labored breathingor persistent cyanosis, regardless ofgestational age (GA).6,7

CPAP improves oxygenation inpreterm infants with respiratorydistress syndrome (RDS).8 CPAP mayalso improve functional residualcapacity, respiratory work, and gasexchange.9 The effect of positivepressure on lung volume increaseswith lung elasticity, which is directlyrelated to GA, and decreases withchest wall elasticity, which isinversely related to GA.7,10 Theamount of pressure required to causelung rupture decreases withincreasing GA because of increaseddistensibility and decreased surfacetension.11 The association betweenCPAP and air leak syndrome has beena concern in neonatal literature.12 Inthe Continuous Positive AirwayPressure or Intubation at Birth(COIN) trial, increased air leak in DR-CPAP versus DR intubation may haveresulted from a higher level of CPAPthan in similar studies.4,13 CPAP is anappropriate DR therapy for mosthypoxia or labored breathing in

preterm infants that is caused by RDSor retained lung fluid (bothassociated with decreased lungcompliance). However, in terminfants, RDS prevalence is low.Grunting, nasal flaring, or retractionsmay result from diagnoses for whichDR-CPAP administration is nota proven therapy, such as fetalacidemia, perinatal asphyxia,pulmonary hypertension,pneumothorax, congenitaldiaphragmatic hernia, polycythemia,fever, sepsis, or hypoglycemia.14,15

Therefore, we hypothesized that inlate-preterm and term infants, the useof DR-CPAP would be associated withincreased frequency of symptomaticpneumothorax.

METHODS

Design

This was a retrospective birth cohortstudy with a nested cohort.

Patients

Entry criteria for the birth cohortincluded infants 35 to 42 weeks’ GAborn at PHHS between 2001 and2015. To further assess the effects ofDR-CPAP, we selected a nested cohortof at-risk infants (1) treated bya resuscitation team (which couldprovide DR-CPAP), (2) with extensiveavailable information (available inthose born between 2005 and 2015who were admitted to the NICU), and(3) excluding those who received DRpositive-pressure ventilation (PPV).

Setting

At PHHS, deliveries for infants 35 to42 weeks’ GA are typically attendedby a provider from the newbornnursery who may use PPV withoutpositive end-expiratory pressure,using a self-inflating bag. The PHHSNICU resuscitation team is called forinfants 35 to 42 weeks’ GA at highrisk for needing resuscitation (eg,malformations), fetal compromise (ie,nonreassuring fetal heart tones), orpoor respiratory effort not resolving

with short-term PPV with a self-inflating bag. Only the NICUresuscitation team can provide CPAPor positive end-expiratory pressure tonewborns in the DR. Facemask CPAPis provided via NeoPuff T-pieceresuscitator. CPAP is typically startedat 5 cm H2O and further escalated toa maximum of 8, if needed, in the DRor later in the NICU, on the basis ofchest radiograph findings and oxygenrequirement. PHHS adopted the NRPguidelines including DR-CPAP inspontaneously breathing infants withrespiratory distress or hypoxia in July2011. Criteria for NICU admission arelisted online (SupplementalInformation).

Data Sources

Data were obtained from theParkland neonatal resuscitation andNICU databases. The neonatalresuscitation database isa compilation of data since 2005pertaining to DR resuscitation ofnewborns who are admitted to theNICU as well as data at the time ofadmission to the NICU. The ParklandNICU database provides data duringtheir NICU stay.

Outcome Variables

The primary outcome of the birthcohort was the change in percentageof pneumothorax afterimplementation of the new NRPguidelines.

The primary outcome of the nestedcohort was the odds ratio (OR) ofpneumothorax of infants whoreceived DR-CPAP versus those whodid not receive DR-CPAP. Secondaryoutcomes included the use of DR-CPAP and the comparison of OR ofpneumothorax with CPAP in infantsreceiving 21% oxygen in the DRversus OR in those receiving oxygensupplementation.

Approval

This study was approved by theUniversity of Texas Southwestern

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Medical Center Institutional ReviewBoard and by PHHS.

Statistical Analysis

Continuous variables are presentedas mean (SD) or median(interquartile range). Changes overtime (with participation in SUPPORTand after implementation of the newNRP guidelines) were analyzed eitherby statistical process control (Pcontrol chart) by using QI Macros forExcel (KnoWare International,Denver, CO) if values were stable orby time series analysis to analyzesignificance of trends. Otherstatistical analyses were conductedby using SPSS version 23 (IBM, Inc,Armonk, NY) or SAS version 14.2(SAS Institute, Inc, Cary, NC) for 2-tailed tests, with P , .05 consideredsignificant. Continuous variables wereanalyzed by using Student t test,Mann-Whitney test, or time seriesanalysis. Dichotomous outcomes wereanalyzed by x2 analysis (exact testfollowed by pairwise comparisonswith Bonferroni correction, asappropriate) and Cochran-Mantel-Haenszel test.

Because this was a retrospectiveobservational study, the associationbetween DR-CPAP and pneumothoraxcould have resulted from biasbecause of unequal distribution ofprognostic factors between patientsexposed (treated) or not exposed(controls) to DR-CPAP. Four approacheswere used to adjust for bias.16

First, stepwise logistic regressionanalysis was conducted to adjust forconfounders.

Second, the analysis was adjusted forDR oxygen administration by testingfor an additive interaction betweenDR-CPAP and DR oxygen.

Third, propensity score analysis wasconducted to reduce imbalancebetween treated neonates andcontrols on many covariates mergedinto a single variable, the propensityscore. As recommended by Austin, thepropensity score for pneumothorax

included all variables available in theDR (excluding CPAP) and soon afterNICU admission that reachedsignificance on forward stepwiseregression as well as the change inpractice recommended by the NRP.17

Each treated neonate was matched byusing a SAS macro18 with 2 controlswhose propensity scores differedfrom the treated infant by ,0.01 (ie,caliper matching).19 Imbalance ofcovariates was assessed by thestandardized difference, using a SASmacro.17,20

Fourth, instrumental variable analysiswas used to control for unmeasuredconfounding. A valid instrumentalvariable is a variable that (1) isindependent of the unmeasuredconfounding, (2) affects thetreatment, and (3) affects theoutcome only indirectly through itseffect on the treatment.21 Epoch(defined by calendar year and changein guidelines) was selected as aninstrumental variable because ofchanges in DR-CPAP use over time.Imbalance of covariates was assessedby the multivariate imbalancecoefficient (ranging from 0 to 1,representing perfect balance andimbalance, respectively), using the GISAS macro.21

To detect a 25% increase infrequency of pneumothorax in thebirth cohort from a baseline of 0.4%with a statistical power of 0.9, a totaln of 9030 patients in each group wasneeded, using x2 analysis. Sample sizeanalysis for the logistic regression inthe nested cohort was sufficient tohave at least 10 subjects withpneumothorax per variable includedin the logistic regression analysis.

RESULTS

Birth Cohort

The birth cohort included 200381neonates born 2001–2015 (Fig 1).The percentage of symptomaticpneumothorax, initially stable,increased progressively afterimplementing the new guidelines(Fig 2). The average percentage ofpneumothorax increased from 0.38%before implementation (561 out of148 591) to 0.56% (292 out of51 790) after implementation of thenew NRP guidelines (P , .05).

Nested Cohort

Among 9304 neonates born at 35to 42 weeks’ GA in 2005–2015 whohad a DR resuscitation team call andwere admitted to the NICU, 6913

FIGURE 1Study participant flow diagram showing the birth cohort (infants 35–42 weeks’ GA born in2001–2015) and the nested cohort (infants 35–42 weeks’ GA born in 2005–2015 who had a DRresuscitation team call, did not receive PPV in the DR, and were admitted to the NICU). O2, oxygen.

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(nested cohort) did not receive PPV(Fig 1).

In the nested cohort, infants whoreceived DR-CPAP had significantlyhigher proportions of placentalabruption, meconium-stainedamniotic fluid, cesarean delivery, andsurfactant administration comparedwith those who did not receive DR-CPAP. Among infants receiving DR-

CPAP, there was a lower proportionof girls and Hispanics and lowerApgar scores (Table 1).

DR-CPAP use increased linearly overtime (r = 0.71, P = .01) (Fig 3). DR-CPAP in neonates requiring oxygensupplementation in the DR increasedduring the SUPPORT trial, thentransiently decreased and did notincrease after implementing the new

NRP guidelines beyond the levelduring SUPPORT (Fig 4). In contrast,DR-CPAP in neonates receiving 21%oxygen increased in 2011 afterimplementing the new NRPguidelines (Fig 4).

Association of CPAP WithPneumothorax

Among 6913 neonates, the frequencyof pneumothorax was 3.7% amongthose who did not receive DR-CPAPand 16.9% among those who receivedDR-CPAP (number needed to harm:8) (Table 2). Administration ofDR-CPAP was significantly associatedwith pneumothorax (OR: 4.6; 95%confidence interval [CI]: 3.6–6.0) inbivariate analysis. This was confirmedin multivariate analyses(Supplemental Tables 3–6). Bothinstrumental variable and propensityscore analyses substantially reducedimbalance of covariates betweentreated patients and controls (Supplemental Tables 4 and 5).

The OR of pneumothorax associatedwith CPAP was higher (P , .001) ininfants receiving 21% oxygen (OR:8.5; CI: 5.9–12.3; P , .001) than inthose receiving oxygensupplementation (OR: 3.5; CI: 2.5–5.0;P , .001) in bivariate analysis (Fig 1).Similar results were obtained inmultivariate analyses (SupplementalTables 5, 7, and 8). The frequency ofpneumothorax was not significantlyassociated with the level of CPAP(P = .68).

Other Outcomes

Pulmonary interstitial emphysemaoccurred in 8 out of 6913 patients: 3out of 1001 on CPAP versus 5 out of5912 without CPAP (P = .01).

Among 388 patients withpneumothorax, 7.9% received eitherthoracocentesis or thoracostomy(Table 2). The percentage oftreatment was similar in those withversus those without DR-CPAP. Thefrequency of treatment was 7 out of210 (3%) in those withoutrespiratory support at the time of

FIGURE 2Evolution of the percentage of neonates with pneumothorax in the birth cohort. The graph showsyear on the x-axis and the percentage of neonates 35 to 42 weeks’ GA with pneumothorax on they-axis. CL, center line; LCL, lower control limit; UCL, upper control limit.

TABLE 1 Perinatal Characteristics of Infants 35 to 42 Weeks’ GA in the Nested Cohort

DR-CPAP No DR-CPAP P

n = 1001 n = 5912

Preeclampsia, n (%) 159 (16) 815 (14) .09Placental abruption, n (%) 12 (1.2) 28 (0.5) .01Meconium-stained fluid, n (%) 285 (29) 1053 (18) ,.001Cesarean delivery, n (%) 657 (66) 3124 (53) ,.001Female, n (%) 416 (42) 2762 (47) .003Race and ethnicity, n (%) .04Hispanic 725 (72)a 4526 (77)a

African-American non-Hispanic 162 (16) 845 (14)White non-Hispanic 78 (8) 377 (6)Other 36 (4) 164 (3)

GA, mean 6 SD, wk 38 6 2 38 6 2 .89Birth wt, mean 6 SD, g 3159 6 669 3123 6 729 .13Intrauterine growth restriction, n (%) 21 (2.1) 264 (4.5) ,.001Apgar 1 min, median (IQR) 8 (7–8) 8 (8–8) ,.001Apgar 5 min, median (IQR) 8 (8–9) 9 (9–9) ,.001Surfactant administration, n (%) 18 (1.8) 19 (0.3) ,.001

Student t test, Mann-Whitney test, or x2 analysis (exact test followed by pairwise comparisons with Bonferroni correction,as appropriate. IQR, interquartile range.a Indicates pairwise comparisons that reached significance.

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diagnosis versus 24 out of 178 (13%)in those on positive airway pressure,P , .001.

Among infants given DR-CPAP,pneumothorax increased with increasingGA and was higher in boys and lower ininfants who received oxygen in the DR(Supplemental Table 9).

DISCUSSION

We present a large birth cohort studyin which an increase inpneumothorax was shown after

implementation of the new NRPguidelines. In a nested cohort, wefound a progressive increase in DR-CPAP in all infants, regardless ofwhether they needed oxygensupplementation or not. DR-CPAPwas associated with increased odds ofpneumothorax. The OR ofpneumothorax with CPAP in neonatesreceiving DR-CPAP and 21% oxygenwas 3 times as high as in thosereceiving DR-CPAP withsupplemental oxygen. Similar resultswere obtained by instrumental

variable analysis and propensityscore analysis. The odds of DR-CPAP–associated pneumothoraxincreased with increasing GA anddecreased with oxygen requirement,suggesting that the risk of CPAP-induced pneumothorax is higher inmore-mature lungs with lessunderlying disease.

The interaction between oxygenadministration and DR-CPAP, as wellas the increasing odds ofpneumothorax with increasing GAamong neonates receiving DR-CPAP,is consistent with Adler’s data inwhich an increased risk ofpneumothorax in neonates withhigher lung compliance andlower chest wall compliance wasshown.10 Moreover, our data areconsistent with previous studies inwhich an association between DR-CPAP and pneumothorax in late-preterm and term neonateswas shown.

In a large Canadian retrospectivecohort study of 71 237 infants, it wasfound that CPAP was protective fromdeveloping pneumothorax in early-preterm neonates but was a riskfactor for pneumothorax in moderate-to-late-preterm and term neonates.22

In 2015, Hishikawa et al23 found thatimplementation of new Japanese

FIGURE 3Evolution of the use of CPAP among neonates in the nested cohort. The graph shows year on thex-axis and the percentage of neonates who received CPAP on the y-axis.

FIGURE 4Control charts of use of CPAP in the DR versus oxygen administration in the DR in the nested cohort. The graphs show year on the x-axis and thepercentage of neonates who received CPAP on the y-axis. A, Oxygen administration in the DR. B, Room air in the DR. CL, center line; LCL, lower control limit;UCL, upper control limit.

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resuscitation guidelines including DR-CPAP was associated with increasedpneumothorax in early-term infantsbut not in those born beyond 38weeks. The association betweenguideline implementation andpulmonary air leak disappearedby adjusting for DR mask CPAP.23

In 2017, Clevenger and Britton24

reported increased odds ofpneumothorax with DR-CPAP(adjusting for GA) both in a case-control study and in a later cohortstudy in term neonates. However,because controls of the cohort studywere healthy, the possibility ofselection bias or confounders was nottaken into account in the analysis,suggesting a possible overestimationof the association between DR-CPAPand pneumothorax.24

In at least 3 randomized trials,researchers have shown the benefit ofCPAP in late-preterm infants andterm infants with respiratorydistress and oxygen requirement inthe NICU. In one study in neonateswith transient tachypnea of thenewborn, DR-CPAP usinga T-piece–based infant resuscitator

versus free-flow oxygen reducedthe duration and severity ofrespiratory distress.25 In anotherstudy among infants withmeconium aspiration syndrome,CPAP reduced the need formechanical ventilation.26 In thethird study among infants born at.30 weeks’ GA with respiratorydistress, CPAP versus headboxoxygen administration reduced theneed for up-transfer of infants withrespiratory distress in nontertiarycenters. There was a clinicallyrelevant but not statisticallysignificant increase inpneumothorax.27

Our study has several strengths thatdistinguish it from previous studies inwhich researchers have evaluatedDR-CPAP and pneumothorax. First,both the birth cohort and the nestedcohort had a large sample size.Second, analysis of the associationof pneumothorax with CPAP wasdone in a nested cohort of high-riskneonates, excluding those whoreceived PPV in the DR, therebyavoiding attribution ofa pneumothorax to CPAP ina patient who also had received PPV.

Third, we evaluated the interactionbetween oxygen requirement andDR-CPAP in regards to probabilityof pneumothorax. This is, toour knowledge, the only study inwhich this interaction has beenexamined.

There were several limitations to ourstudy. First, this was a retrospectiveanalysis, and randomization was notpossible. This weakness was in partmitigated by using 4 methods: logisticregression, analysis adjusted for DRoxygen administration, analysisstratified for epoch as instrumentalvariable, and propensity scoreanalysis.17 Secondly, it was impossibleto distinguish whether some of thepneumothoraxes noted on chestradiograph were in fact spontaneouspneumothoraxes present beforeapplication of DR-CPAP. Third, data oninfants who had a resuscitation teamcall but were not admitted to the NICUare not available because these infantsare not included in the resuscitationdatabase; therefore, the frequency ofpneumothorax among all infants whohad a resuscitation team call could notbe assessed. Fourth, the true overallincidence of pneumothorax in this

TABLE 2 Pneumothorax by Epoch Versus Continuous Positive Pressure and Oxygen Administration in the DR in the Nested Cohort

Epoch Room Air Oxygen Total

No DR-CPAP DR-CPAP No DR-CPAP DR-CPAP No DR-CPAP DR-CPAP

No. patients with pneumothorax outof total no. patients (%)2005 12 out of 251 (5) 0 out of 1 (0) 9 out of 238 (4) 6 out of 52 (12) 21 out of 489 (4) 6 out of 53 (11)2006 5 out of 280 (2) — 10 out of 260 (4) 8 out of 60 (13) 15 out of 540 (3) 8 out of 60 (13)2007 29 out of 495 (6) 0 out of 1 (0) 9 out of 50 (18) 8 out of 49 (16) 38 out of 545 (7) 8 out of 50 (16)2008 17 out of 478 (4) 0 out of 2 (0) 3 out of 45 (7) 12 out of 72 (17) 20 out of 523 (4) 12 out of 74 (16)2009 24 out of 504 (5) 0 out of 1 (0) 3 out of 28 (11) 5 out of 48 (10) 27 out of 532 (5) 5 out of 49 (10)2010 12 out of 423 (3) 2 out of 16 (13) 2 out of 67 (3) 13 out of 90 (14) 14 out of 490 (3) 15 out of 107 (14)2011aa 3 out of 186 (2) 1 out of 15 (7) 0 out of 30 (0) 2 out of 20 (10) 3 out of 216 (1) 3 out of 35 (9)2011ba 12 out of 258 (5) 3 out of 18 (17) 3 out of 50 (6) 10 out of 36 (28) 15 out of 308 (5) 13 out of 54 (24)2012 15 out of 538 (3) 8 out of 39 (21) 4 out of 81 (5) 2 out of 66 (3) 19 out of 619 (3) 10 out of 105 (10)2013 17 out of 482 (4) 11 out of 45 (24) 4 out of 82 (5) 22 out of 110 (20) 21 out of 564 (4) 33 out of 155 (21)2014 10 out of 432 (2) 9 out of 34 (27) 3 out of 86 (4) 13 out of 97 (13) 13 out of 518 (3) 22 out of 131 (17)2015 9 out of 510 (2) 19 out of 59 (32) 3 out of 58 (5) 16 out of 69 (23) 12 out of 568 (2) 35 out of 128 (27)2005–2015 165 out of 4837 (3) 53 out of 231 (23) 53 out of 1075 (5) 117 out of 770 (15) 218 out of 5912 (4) 170 out of 1001 (17)

No. patients needingthoracocentesisor thoracostomy out of total no.with pneumothorax (%)2005–2015 8 out of 165 (5) 7 out of 53 (13) 7 out of 53 (13) 9 out of 117 (8) 15 out of 218 (7) 16 out of 170 (9)

—, not applicable.a 2011a and 2011b are before and after implementation of the new NRP guidelines, respectively.

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cohort is not known because chestradiograph was obtained only insymptomatic neonates.

With the findings from our study, 2clinical implications are suggested.First, caution should be appliedregarding providing DR-CPAP,especially in the term population.Second, the use of CPAP should be re-evaluated as therapy for grunting,nasal flaring, or tachypnea in infants35 to 42 weeks’ GA without anoxygen requirement in the DR. Thesefindings could be used to clarify NRPguidelines regarding the use ofDR-CPAP. Further studies maybe necessary to clarify the role DR-

CPAP plays in the treatment of terminfants with oxygen requirement inthe DR.

ACKNOWLEDGMENTS

We thank Patti Jeannette Burchfield,RN, for her work in collecting andextracting data for the NICU database.We thank Lucy Christie, RN, and AnitaThomas, RN, for their work incollecting and extracting data for theresuscitation database. Theirexpertise made this project possible.We also thank Robert Haley, MD, forhis help with propensity scoreanalysis.

ABBREVIATIONS

CI: confidence intervalCPAP: continuous positive airway

pressureDR: delivery roomGA: gestational ageNRP: Neonatal Resuscitation

ProgramOR: odds ratioPHHS: Parkland Health and

Hospital SystemPPV: positive-pressure

ventilationRDS: respiratory distress

syndrome

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1720.

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Venkatakrishna Kakkilaya, L. Steven Brown, David B. Nelson and Luc P. BrionWilliam Smithhart, Myra H. Wyckoff, Vishal Kapadia, Mambarambath Jaleel,Delivery Room Continuous Positive Airway Pressure and Pneumothorax

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DOI: 10.1542/peds.2019-0756 originally published online August 9, 2019; 2019;144;Pediatrics 

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