Original Article

Impact of Prophylactic Continuous Positive

Airway Pressure on Transient Tachypnea of the
Newborn and Neonatal Intensive Care Admission
in Newborns Delivered by Elective Cesarean
Section
Miray Yilmaz Celebi, MD1 Serdar Alan, MD2 Dilek Kahvecioglu, MD3 Ufuk Cakir, MD3
Duran Yildiz, MD3 Omer Erdeve, MD3 Saadet Arsan, MD3 Begum Atasay, MD3

1 Department of Pediatrics, Ankara University School of Medicine, Address for correspondence Serdar Alan, MD, Vedat Dolakay Cad. No:
Ankara, Turkey 90A/16 Gaziosmanpasa, 06100 Ankara, Turkey
2 Neonatal Intensive Care Unit, Hitit University Corum Training and (e-mail: [email protected]).
Research Hospital, Corum, Turkey
3 Division of Neonatology, Department of Pediatrics, Ankara University
School of Medicine, Ankara, Turkey

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Am J Perinatol

Abstract Objective This study aims to evaluate the effect of the prophylactic continuous
positive airway pressure (CPAP) administration in the delivery room to newborns who
were delivered by elective cesarean section (CS).
Study Design Inborn infants with gestational age between 340/7 to 386/7 and born by
elective CS were prospectively randomized to receive either prophylactic CPAP for 20
minutes via face mask or standardized care without CPAP in the delivery room. Primary
outcomes were the incidence of transient tachypnea of the newborn (TTN) and neonatal
intensive care unit (NICU) admission due to respiratory distress.
Results A total of 259 infants with a mean gestational age of 37.7
0.8 weeks and
Keywords birth weight of 3,244
477 g were included. A total of 134 infants received prophy-
► continuous positive lactic CPAP and 125 received control standard care. The rate of NICU admission was
airway pressure significantly lower in prophylactic CPAP group (p ¼ 0.045). Although the rate of TTN
► late preterm was lower in the prophylactic CPAP group, the difference was not statistically significant
► early term (p ¼ 0.059). The rate of NICU admission due to respiratory distress was significantly
► delivery room higher in late-preterm cohort than early-term cohort (p < 0.0001).
► transient tachypnea Conclusion Prophylactic CPAP administration decreases the rate of NICU admission
of the newborn without any side effect in late-preterm and early-term infants delivered by elective CS.

The incidence of respiratory morbidity following elective most common respiratory morbidities and are related to
cesarean section (CS) in term infants varies from 3.5 to gestational age (GA) in late-preterm infants. RDS and TTN
12.4%.1–6 Transient tachypnea of the newborn (TTN) is the occur in 10.5 and 6.4% of infants, respectively, at 34 weeks of
most frequent cause of respiratory morbidity in term in- gestation; these incidences decrease with gestational age to
fants.4,6 Respiratory distress syndrome (RDS) and TTN are the 2.8 and 2.5%, respectively, at 36 weeks of gestation.7

received Copyright © by Thieme Medical DOI http://dx.doi.org/

February 27, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1560041.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
June 26, 2015 Tel: +1(212) 584-4662.
Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

Risk factors associated with TTN are male sex, a heavier Description of Study Groups and Study Intervention
birth weight (BW), maternal diabetes, twin pregnancy, pre- After elective CS, the patients were randomly assigned to one
term birth, and CS.8–10 According to the current literature, of two experimental groups within 5 minutes using computer-
avoidance of elective CS before the onset of labor, and based randomization. The infants were randomized to receive
administration of antenatal steroids before elective CS at 37 either prophylactic CPAP or standardized care without CPAP in
to 39 weeks of gestation are among the preventive strategies the delivery room. In twin pregnancies, randomization was
for TTN.6,8,11 performed for only the first infant; the second infant was
Although the use of very early (prophylactic) continuous included in the other group without randomization. After
positive airway pressure (CPAP) of at least 5 to 6 cm H2O in elective CS delivery, infants in both groups were stabilized
spontaneously breathing preterm infants is currently recom- on a radiant warmer, and a pulse oximetry probe was applied
mended for reducing surfactant administration and enhancing to the right wrist for measurement of O2 saturation (Nellcor
lung protection in the delivery room,12 no data are available on N-560 Pulse Oximetry Monitor; Covidien, Dublin, Ireland).
prevention of respiratory morbidity by delivery room man- In the prophylactic CPAP group (group 1), CPAP was
agement in early-term and late-preterm infants. There is an applied in the delivery room at a pressure of 5 cm H2O
urgent need to explore therapeutic strategies that can enhance with FIO2 established at 24 to 30% using an appropriately
lung fluid clearance and facilitate transition in infants deliv- sized face mask starting 5 to 10 minutes after birth and lasting
ered by elective CS. We hypothesized that in the delivery room, 20 minutes. A T-piece resuscitator with oxygen blender
prophylactic CPAP administration to newborns with an (Neopuff Infant Resuscitator; Fisher-Paykel, Auckland, New
increased risk of TTN (delivered by elective CS and born Zealand) was used in the delivery room for the CPAP admin-
from 340/7 to 386/7 weeks of gestation) would decrease the istration. The flowmeters were set at 1 L/min for oxygen and 7
rate of neonatal intensive care unit (NICU) admission due to L/min for air according to manufacturer recommendation. In

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respiratory distress and the incidence of TTN. the control group (group 2), prophylactic CPAP was not
applied in the delivery room (►Fig. 1).
After an intervention period, when the infants had ta-
Materials and Methods
chypnea (> 60/min) and one of the following respiratory
Patients and Setting distress signs: (1) apnea; (2) grunting sounds with breathing;
This prospective randomized study was conducted in a single (3) flaring of the nostrils; (4) retractions; (5) oxygen require-
NICU from October 2012 to September 2013. The trial was ment (cyanosis), their follow-up was continued up to 2 hours
approved by the Human Research Ethics Committee of An- of age in the delivery room. If their respiratory signs wors-
kara University School of Medicine. Informed consent was ened or continued during the first 2 hours of life, infants were
obtained from the parents of the patients before delivery. admitted to the NICU. On the other hand, infants without
Inborn infants from 340/7 to 386/7 weeks of gestation and respiratory distress or infants whom respiratory distress
born by elective CS were enrolled. The exclusion criteria were resolved (the absence of clinical sign of respiratory distress,
as follows: normal vaginal delivery, CS performed during transcutaneous oxygen saturation of > 90% without oxygen,
spontaneous labor, born at < 34 or  39 weeks of gestation, respiratory rate < 60/min) within 2 hours were left to the
resuscitation needed in the delivery room (including posi- mother care (►Fig. 1).
tive-pressure ventilation), congenital malformation of the
respiratory system, antenatal steroid exposure, early mem- Definitions
brane rupture (> 18 hours), chorioamnionitis, and refusal of Delivery room care included close monitoring of vital signs,
parental consent. transcutaneous oxygen saturation, and oxygen therapy if

Fig. 1 The sequence of enrollment and study intervention.

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 Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

needed after the stabilization and intervention periods and Outcomes

before hospitalization, up to the first 2 hours of life (►Fig. 1). The primary outcomes were the incidence of TTN and NICU
The time period was needed for accurate assessment of the admission with any respiratory symptoms.
respiratory condition to decide the hospitalization. The heart rate (HR), RR, and saturation of partial oxygen
Elective CS was defined as CS performed before the onset of (SpO2) were recorded at the beginning of the study (0
spontaneous labor without any serious maternal or fetal minutes); at 5, 10, 15, 20, 30, 60, and 120 minutes of study;
problems in term pregnancies.13 For preterm pregnancies, and at 6 hours of life. MSS was calculated to evaluate the
elective CS was defined as CS performed due to maternal severity of respiratory distress.
problems before the onset of spontaneous labor. We recorded the following patient characteristics: GA, BW,
A late-preterm infant was defined as an infant born from sex, Apgar score at 1 and 5 minutes, indications for elective CS,
340/7 to 366/7 weeks of gestation. An early-term infant was and complications of the prophylactic CPAP therapy via the
defined as an infant born from 370/7 to 386/7 weeks of face mask, including the rates of air leakage (pneumothorax),
gestation.14 gastric distension, and nasal or facial trauma.
The modified-Silverman score (MSS) was calculated ac-
cording to ►Table 1.15 Statistical Analysis
The diagnosis of TTN was established based on the follow- Sample size calculation was based on the primary outcome
ing clinical and laboratory data: (1) onset of tachypnea with a variable, namely, the diagnosis of TTN. The power calculation
respiratory rate (RR) of > 60 breaths/min within 6 hours after was performed according to the data from a previous study
birth, grunting sounds with breathing, flaring of the nostrils, which was conducted in our NICU on the association between
and retractions; (2) persistence of tachypnea for at least 12 cord hormones and TTN in late-preterm and term newborns
hours; (3) chest radiograph indicating at least one of the who were born by CS.18 The incidence of TTN was 4.2%,

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following: prominent central vascular markings, widened according to that study. A total sample size of 250 (125 for
interlobar fissures of pleural fluid, symmetrical perihilar prophylactic CPAP group, 125 for Control group) was required
congestion, hyperaeration as evidenced by flattening and to detect a 20% difference in the incidence of TTN between
depression of the diaphragmatic domes or increased ante- groups with a power of 85% at the 5% significance level.
roposterior diameter or both; and (4) exclusion of all other The results were analyzed with SPSS for Windows 15.0
known respiratory disorders, such as RDS, meconium aspira- (SPSS Inc., Chicago, IL). Differences between groups for cate-
tion, congenital heart disease, and nonrespiratory disorders gorical variables were analyzed by the chi-square test or
likely to cause tachypnea (hypocalcemia, persistent hypogly- Fisher exact test, where appropriate. Continuous variables
cemia, polycythemia).16 were compared between groups by using independent t-test
Delayed transition was retrospectively diagnosed when and/or Mann–Whitney U test. Descriptive statistics were
symptoms resolved within the first few hours of life instead of presented as percentages or mean
standard deviation
progressing as RDS, TTN, or meconium aspiration and median (minimum–maximum). To define effects of using
syndrome.17 delivery room CPAP on NICU admission and diagnosis of TTN,
Indication for nCPAP treatment was based on clinical binary logistic regression were performed and adjusted odds
signs and/or laboratory findings after hospitalization. The ratios; their confidence intervals (CIs) were calculated. To
presence of the following criteria was used: (1) grunting obtain number needed to treat (NNT) ratios, we used the
and/or retractions; (2) respiratory rate > 60/min for  2 general (1/[treatment group event rate  control group
hours; (3) oxygen requirement  2 hours (low transcuta- event rate]) formula and summarized them with related
neous oxygen saturation < 90% under oxygen treatment; 95% CIs. Any p value less than 0.05 were considered statistical
(4) arterial blood gas: PCO2 > 50 mm Hg, PO2 < 50 mm Hg significant.
(FIO2 > 60%); (5) the absence of air leak on the chest
radiography. Initial nCPAP parameters were 5 to 6 cm
Results
H2 O positive end-expiratory pressure and FIO2 40%, which
was varied to keep oxygen saturation between 92 and 96%. In total, 2,677 infants were born in our center during the study
period, and 825 of them were born via elective CS and

Table 1 Modified Silverman score

0 1 2
Chest wall Synchronized Lag on inspiration Seesaw
Subcostal retraction None Just visible Marked
Xiphoid retraction None Just visible Marked
Nasal flaring None Minimal Marked
Grunting None Stethoscope only Naked ear

American Journal of Perinatology

Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

assessed for eligibility. Of these 825 infants, 259 (31.4%) were SpO2 was significantly higher at 5, 10, 15, 20, and 30 minutes
included in the study and randomized to the two study in prophylactic CPAP group (►Table 3).
groups. Of the eligible infants, 134 underwent prophylactic In total, 51 (19.6%) of the study infants (20 [14.9%] in group
CPAP and 125 served as controls (►Fig. 2). 1 vs. 31 [24.8%] in group 2, p ¼ 0.046) required delivery room
The indications for elective CS were as follows: manage- care because of their oxygen requirements and respiratory
ment of previous CS (n ¼ 157, 60.6%), maternal request symptoms in the first 2 hours of life. Out of these infants 15
(n ¼ 38, 14.7%), multiple pregnancies (n ¼ 23, 8.9%), the (5.8%) were admitted to the NICU because of worsening
presence of malpresentation (n ¼ 20, 7.7%), and other rea- respiratory distress. The NICU admission rate was 3%
sons, including maternal genital infection, a history of ma- (n ¼ 4) in group 1 and 8.8% (n ¼ 11) in group 2
ternal surgery, placenta previa, and cephalopelvic (p ¼ 0.045). Of the 15 infants, 7 (7/259, 2.7%) were diagnosed
dissociation (n ¼ 21, 8.1%). The mean GA and BW of the with TTN. One infant (0.7%) with TTN was in group 1, and the
study infants were 37.7
0.8 weeks of gestation and remaining 6 (4.8%) were in group 2 (p ¼ 0.059) (►Table 4).
3,244
477 g, respectively. Of the study infants, 35 The remaining eight infants were diagnosed with delayed
(13.5%) were late preterm and 234 (86.5%) were early transition.
term. The median Apgar scores at 1 and 5 minutes were 8 The mean GA in infants with TTN was 37.1
0.9 weeks,
(range, 5–9) and 9 (range, 8–10), respectively. In total, 131 of and all of them required nCPAP and/or bilevel nCPAP therapy
the study infants (50.6%) were males. A total of 39 (31.2%, 39/ for a median duration of 14 hours (range, 7–23 hours) during
125) infants who were in the control group had an oxygen their NICU stay. The median stay in the NICU was 2 days
supply during the intervention period. (range, 1–6 days) in infants with TTN. The mean GA in infants
There were no significant differences in the patient char- with delayed transition was 35.9
1.9 weeks, and none of
acteristics or MSS between groups 1 and 2 (►Table 2). No them required nCPAP therapy. The median NICU stay was

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complication of prophylactic CPAP therapy (air leakage, gas- 4 days (range, 1–13 days) in infants with delayed transition.
tric distension, and nasal or facial trauma) was observed in Three infants who stayed for 13 days in the NICU were born as
group 1 (n ¼ 0). triplets at 34 weeks of gestation and had feeding difficulty. No
Comparison of the HR, RR, and SpO2 measurements at 0, 5, infants who were admitted to the NICU required mechanical
10, 15, 20, and 30 minutes and at 1, 2, and 6 hours are shown ventilator support.
in ►Table 3. The median HR was significantly higher at 20 and Admission rate due to respiratory distress was not reduced
30 minutes in group 1 than group 2 (p ¼ 0.020 and by application of prophylactic CPAP in the delivery room for
p < 0.0001, respectively). The median RR was significantly late-preterm and early-term infants born by elective CS (odds
higher at all time-points except at 6 hours, and the median ratio [OR], 3.134; 95% CI, 0.971–10.101; p ¼ 0.056). The NNT

Fig. 2 Flow diagram of assessing and including eligible participants in the trial.

American Journal of Perinatology

 Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

Table 2 Demographic characteristics of the infants in two groups

Group 1 (prophylactic CPAP) Group 2 (control) p Value

n ¼ 134 n ¼ 125
Gestational age, mean
SD (wk) 37.6
0.7 37.7
0.8 0.660
0/7 6/7
Late preterm (34 –36 wk), n (%) 15 (11.1) 20 (16)
Early term (370/7–386/7), n (%) 119 (88.9) 115 (84)
Birth weight, mean
SD (g) 3,294
491 3,190
457 0.077
Male sex, n (%) 68 (50.7) 63 (50.4) 0.956
Apgar 1, median (range) 8 (6–9) 8 (5–9) 0.301
Apgar 5, median (range) 9 (8–10) 9 (8–10) 0.087
Modified Silverman score, median (range) 0 (0–7) 0 (0–7) 0.947
Indications of elective CS, n (%)
Management of previous CS 88 (65.7) 69 (55.2) 0.171
Maternal request 15 (11.2) 25 (20)
Multiple pregnancies 10 (7.5) 13 (10.4)
Failure to progress and malpresentation 9 (6.7) 11 (8.8)
Other reasons 12 (9) 7 (5.6)

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Abbreviations: CS, cesarean section; CPAP, continuous positive airway pressure; SD, standard deviation.

was 18 for NICU admission (95% CI, 8.7–1,364.1). Similar edge, our trial is unique in that we applied prophylactic CPAP
effect without statistical significance was observed for TTN to late-preterm and early-term infants who were born by
(OR, 6.711; 95% CI, 0.795–55.55). The NNT was 25 for TTN elective CS and had an increased risk of respiratory distress.
(95% CI, 12.4–3,033.9). The percentage of infants with TTN was lower in the prophy-
lactic CPAP group than in the control group without any
Subgroup Analysis complications, but the difference did not reach statistical
A total of 11 late-preterm infants (11/35, 31.4%) and 40 of the significance. However, the rate of NICU admission due to
early-term infants (40/224, 17.9%) required close monitoring respiratory distress was significantly lower in the prophylac-
and care in the delivery room because of their oxygen tic CPAP group (p ¼ 0.045). The rate of NICU admission due to
requirements and respiratory symptoms in the first 2 hours respiratory distress was significantly higher in the late-pre-
of life (p ¼ 0.06). Eight of the late-preterm infants (8/35, term cohort than in the early-term cohort. Although there
22.9%) versus seven of the early-term infants (7/224, 3.1%) was a tendency toward a higher percentage of TTN in the late-
were admitted to the NICU because of respiratory distress preterm infants than in the early-term infants, the difference
(p < 0.0001). Of the 35 late-preterm infants, 3 (8.6%) were did not reach statistical significance.
diagnosed with TTN; of the 224 early-term infants, 4 (1.8%) Fluid clearance, establishment of an air-filled functional
were diagnosed with TTN (p ¼ 0.054). residual capacity (FRC), and establishment of spontaneous
Among the late-preterm infants, the NICU admission rate breathing are the basic requirements for gas exchange during
was 10% (n ¼ 2) in group 1 and 40% (n ¼ 6) in group 2 the pulmonary transition after birth. Rapid clearance of fetal
(p ¼ 0.051). TTN was diagnosed in 5.0% of late-preterm lung fluid is a key aspect of the transitional period in the delivery
infants (n ¼ 1) in group 1 and 13.3% (n ¼ 2) in group 2 room.20 According to a study by Hooper et al,21 who used phase-
(p ¼ 0.565) (►Table 4). contrast X-ray imaging to observe the rate and spatial pattern of
Among the early-term infants, the NICU admission rate lung aeration at birth in rabbit pups delivered by CS, residual
was 4.5% (n ¼ 2) in group 1 and 1.8% (n ¼ 5) in group 2 liquid clearance from the airways is closely associated with
(p ¼ 0.274). TTN was diagnosed in no early-term infants in inspiratory activity. On the other hand, the authors detected
group 1 (n ¼ 0) and 3.6% (n ¼ 4) in group 2 (p ¼ 0.057) no significant distal movement of the air/liquid interface be-
(►Table 4). tween breaths.21 These findings indicate that the transpulmo-
nary pressure generated by inspiratory effort also plays a critical
role in the airway liquid clearance.21 Measurements of respira-
Discussion
tory activity in healthy term infants at birth indicate that the first
CPAP is widely used for the treatment of early respiratory breaths tend to be deeper and longer than subsequent breaths
problems in late-preterm and term infants, including TTN, and are characterized by a short, deep inspiration followed by a
congenital pneumonia, meconium aspiration syndrome, and prolonged expiratory phase due to glottis closure.22 These are
primary pulmonary hypertension.19 To the best of our knowl- called expiratory breaking maneuvers and provide FRC despite

American Journal of Perinatology

Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

Table 3 The median of heart rate, respiratory rate, and SpO2 levels at 0, 5, 10, 15, 20, 30 min of the study and at 1, 2, and 6 h of the
study in the two groups

Group 1 (CPAP) Group 2 (control) p Value

n ¼ 134 n ¼ 125
Heart rate
Time of intervention
0th min 167.5 (109–214) 166 (98–202) 0.870
th
5 min 159 (114–211) 162 (102–214) 0.657
th
10 min 157.5 (112–212) 157 (112–212) 0.743
th
15 min 157 (113–202) 154 (111–198) 0.239
20th min 155 (107–200) 150 (110–203) 0.020
th
30 min 156.5 (114–205) 148 (110–198) < 0.0001
st
1 h 145 (110–200) 142 (110–190) 0.055
2nd h 139 (112–178) 136 (108–184) 0.280
6th h 134.5 (100–192) 135 (105–168) 0.568
Respiratory rate
Time of intervention

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0th min 68 (38–88) 64 (40–82) 0.003
th
5 min 64 (38–88) 62 (40–86) 0.001
th
10 min 62 (36–80) 60 (32–80) 0.001
15th min 60 (36–84) 56 (34–88) 0.003
th
20 min 56 (35–78) 52 (32–80) 0.005
th
30 min 54 (36–84) 50 (34–80) 0.001
1st h 51 (34–78) 48 (30–88) 0.006
2nd h 48 (34–78) 44 (32–88) 0.009
th
6 h 44 (32–67) 44 (33–82) 0.165
SpO2
Time of intervention
0th min 74 (44–100) 72 (50–89) 0.702
th
5 min 96 (77–100) 88 (60–100) < 0.0001
10th min 98 (82–100) 94 (78–100) < 0.0001
th
15 min 99 (90–100) 96 (84–100) < 0.0001
th
20 min 99 (92–100) 98 (86–100) < 0.0001
30th min 97 (91–100) 98 (89–100) 0.017
st
1 h 98 (92–100) 98 (79–100) 0.320
nd
2 h 98 (91–100) 98 (92–100) 0.673
th
6 h 98 (92–100) 98 (93–100) 0.136

Abbreviation: CPAP, continuous positive airway pressure.

the fact that newborns have relatively floppy chest walls after suggested that lower cord levels of cortisol, adrenocorticothro-
birth.23 On the other hand, amiloride-sensitive sodium transport phic hormone, and free triiodothyronine in patients with TTN
by the lung epithelia through epithelial sodium channels and may indicate a possible relationship between these hormones in
mechanical forces during vaginal delivery are two known mech- fetal lung fluid clearance and postnatal pulmonary adaptation
anisms for clearance of fetal lung fluid.24 In particular, the lungs through their modulatory effect on epithelial sodium channels
of preterm infants are less responsive to mechanisms, such as and Na-K-ATPase.18
sodium reabsorption, and are thus less efficient at clearing lung The clinical goals of CPAP are to maintain the FRC of the
liquid.22 Disruption of this process has been implicated in several lungs and support gas exchange to reduce apnea, work of
disease states, including TTN and RDS.20 Moreover, Atasay et al18 breathing, and lung injury.19 CPAP mimics the natural

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 Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

Table 4 NICU admission and TTN rates of whole-study infants and subgroups

Prophylactic CPAP Control p Value

Whole-study infants (n ¼ 259) n ¼ 134 n ¼ 125
NICU admission 4 (3%) 11 (8.8%) 0.045
TTN 1 (0.7%) 6 (4.8%) 0.059
Late-preterm infants (n ¼ 35) n ¼ 20 n ¼ 15
NICU admission 2 (10%) 6 (40%) 0.051
TTN 1 (5%) 2 (13.3%) 0.565
Early-term infants (n ¼ 224) n ¼ 114 n ¼ 110
NICU admission 2 (1.8%) 5 (4.5%) 0.274
TTN 0 4 (3.6%) 0.057

Abbreviations: CPAP, continuous positive airway pressure; NICU, neonatal intensive care unit; TTN, transient tachypnea of the newborn.

physiologic reflex of grunting that is frequently exhibited in addition, the higher median Sp O2 at 5, 10, 15, 20, and 30
infants with low lung compliance and low end-expiratory minutes were associated with the effects of CPAP and O2 in
lung volume and may generate higher intra-alveolar air our trial. Although about one third of the infants in the

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pressure during expiratory breaking maneuvers after control group needed oxygen supply during stabilization
birth.19,21–23 Infants with lung disease also develop tachyp- period, reduced NICU admission due to respiratory distress
nea to reduce the expiratory time and thus limit exhalation of in the CPAP group may be related to both of the CPAP and
gases to preserve the end-expiratory lung volume. CPAP O2. Mulrooney et al27 demonstrated that spontaneously
reduces tachypnea and increases FRC and PaO2, decreases breathing premature lambs maintained at a CPAP level of
intrapulmonary shunting, improves lung compliance, and 8 cm H2O had better oxygenation than did animals main-
aids in the stabilization of the floppy infant chest wall.19,23 tained at a CPAP level of 5 cm H2 O for 6 hours.
We thought that these benefits of CPAP might be useful when Weintraub et al28 reported that 45% (336/745) of infants
applied prophylactically in late-preterm and early-term new- with TTN required CPAP or high-flow nasal cannula treatment
borns at risk of developing respiratory distress due to deteri- for respiratory support.28 In the present study, all infants with
oration of the transition period. We also reduced the NICU TTN required noninvasive respiratory support for a median
admission rate due to respiratory distress by administration duration of 14 hours (range, 7–23 hours). However, none of
of prophylactic CPAP in the present trial. the infants with delayed transition required noninvasive or
The rate of respiratory distress at birth among term infants invasive respiratory support therapy.
born by elective CS ranges from 3 to 7% in previous stud- The NICU admission rate was significantly higher in the
ies.2,3,25 In the present study, 19.6% of the infants born by late-preterm subgroup than in the early-term group, as
elective CS had signs of respiratory distress. However, only expected (22.9 vs. 3.1%, respectively; p < 0.0001). The NICU
5.8% required NICU admission due to respiratory distress. The admission rate differed according to the GA in late-preterm
incidence of TTN varies from 0.3 to 3.0% for infants delivered infants (67.4% at 34 weeks of gestation vs. 22.1% at 36 weeks of
vaginally and from 0.9 to 12.0% for infants delivered by gestation). The NICU admission rates also differed in early-
elective CS.13 This wide range in the incidence of TTN in term infants, according to the GA (11.8% at 36 weeks of
infants born by elective CS is mainly due to the GA of the gestation vs. 7.2% at 38 weeks of gestation).7
patients. In the present study, the incidence of TTN was 2.7% Recently Tsuda et al suggested that placenta previa in
for infants delivered by elective CS. In addition, TTN was itself is a risk factor for neonatal TTN.29 The present study
detected in 46.6% of the newborns who required NICU also included two newborns who were born by elective CS
admission. Elective CS is known as a major risk factor for due to placenta previa. However, both of them did not
TTN.5–7 According to the data from the National Institutes of develop TTN.
Health, the rate of CS delivery in 2004 climbed to 29.1%.26 The present study had a few limitations. First, it was not
Similarly, the major cause of CS delivery in the present study blinded and because of the lack of the block randomization,
was management of a previous CS (60%). the number of late-preterm infants was very small. Second,
The pediatrician (M. Y. C.) performed CPAP administra- the total number of TTN cases was very small. Therefore, the
tion by face mask for all infants in group 1. The higher HRs larger and blinded study is necessary to overcome the limi-
and RRs had been reversible in the prophylactic CPAP tations of the present study. In conclusion, this study dem-
group. It might be caused by the noxious stimuli of the onstrated that prophylactic CPAP can be used without any
mask or the pressure applied. CPAP administration might complications during the transitional period in the delivery
be easier for investigators and less noxious for infants if room. This approach decreases the rate of NICU admission
binasal short prong or fixed nasal mask were used. In due to respiratory distress.

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Prophylactic Continuous Positive Airway Pressure for Newborns Celebi et al.

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1 Hales KA, Morgan MA, Thurnau GR. Influence of labor and route of water mist on obstructive respiratory signs, death rate and
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nates. Int J Gynaecol Obstet 1993;43(1):35–40 17(1):1–10
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