Initial treatment of preterm infants--continuous positive airway pressure or ventilation?

The question of which strategy is the best in the initial treatment of preterm infants has been on debate for years. Especially in Scandinavia, but also in other parts of the world, there is a strong tradition of early treatment with nasal continuous positive airway pressure (CPAP), while other European and North American centres prefer early intubation and mechanical ventilation. This article gives a brief overview of the history of CPAP, and the current treatment strategies as well as outcomes from a tertiary care Danish neonatal centre are presented. These data suggest that early nasal CPAP may be as good as initial mechanical ventilation with regard to mortality rates and adverse cerebral outcome and perhaps better in preventing chronic lung disease. The results must, however, be interpreted with caution, as the populations in different centres may be incomparable, even when adjustment for severity of illness is performed. A clinical randomized trial comparing initial intubation and mechanical ventilation with initial nasal CPAP using current techniques is therefore not only warranted but is indeed an absolute necessity to answer the question of which treatment is the best.