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Initial CPAP of 5 versus 8 cmH2O during delivery room stabilisation of very preterm infants: the PHILODENDROOM pilot randomised trial

Year: 2026

Type: article

Study designs: Randomized Controlled Trial, Clinical Trial

Abstract: Objective To evaluate the feasibility, safety, and early respiratory effects of two different initial continuous positive airway pressure (CPAP) levels during delivery room (DR) stabilisation of very preterm infants at risk for respiratory distress syndrome (RDS). Methods In this pilot randomised controlled trial conducted at a tertiary neonatal intensive care unit, preterm infants born between 26 + 0 and 29 + 6 weeks’ gestation requiring respiratory support at birth were randomised to receive CPAP at either 5 cmH 2 O or 8 cmH 2 O via face mask and T-piece resuscitator during the first 15 minutes of life. The primary objective was to assess feasibility and safety. The main physiological respiratory outcome was the SpO 2 /FiO 2 (S/F) ratio at 15 minutes of life. Secondary outcomes included need for positive pressure ventilation (PPV), surfactant administration, intubation, air leaks, mechanical ventilation (MV), and bronchopulmonary dysplasia (BPD). Results Fifty-six infants were enrolled and equally randomised between groups. Baseline characteristics were comparable. No significant differences were observed in adverse events, including pneumothorax, pulmonary interstitial emphysema, or DR intubation. The S/F ratio at 15 minutes was similar between groups (271 ± 101 vs 269 ± 111; p = 0.95). The proportion of infants requiring PPV was identical in both groups (35%). Although the overall surfactant administration rate did not differ, infants receiving 5 cmH 2 O reached surfactant treatment threshold earlier than those receiving 8 cmH 2 O (2.2 ± 1.7 vs 3.5 ± 2.1 hours; p = 0.03). Trends towards shorter MV duration and lower BPD incidence were observed in the 8 cmH2O group, without statistical significance. Conclusion Both 5 and 8 cmH 2 O CPAP levels were feasible and safe during DR stabilisation of very preterm infants. Although higher CPAP levels were associated with potentially favourable respiratory trends, the findings also highlight the limitations of relying exclusively on FiO2 thresholds to guide surfactant administration. Adjunctive tools such as lung ultrasound may support a more physiological assessment of lung recruitment during neonatal transition. Larger adequately powered trials are needed to define the optimal initial CPAP strategy.

Source: European Journal of Pediatrics

DOI: 10.1007/s00431-026-07322-6