<scp>EBNEO</scp> Commentary: Extended <scp>CPAP</scp> in Preterm Infants Increases Lung Growth at 6 Months

Bronchopulmonary dysplasia (BPD) is a common and challenging complication of preterm birth. Despite advances in the use of antenatal steroids, surfactant, and lung protective ventilation, rates of BPD are stable or even increasing [1]. Ongoing research into improving respiratory outcomes in preterm infants is essential. In this context, McEvoy et al. investigate whether extended CPAP (eCPAP) beyond respiratory stability enhances lung growth and reduces long-term respiratory issues. First described in the 1970s and gaining popularity in the 2000s, the use of CPAP in the NICU is well established, with early use consistently shown to decrease rates of BPD compared to invasive ventilation by avoiding ventilator-induced lung injury while maintaining FRC, stabilising the compliant chest wall of infants, and accelerating lung tissue growth [2-4]. Early CPAP administration is the standard of care in preterm infants. However, the optimal timing to discontinue CPAP in the stable preterm infant remains unclear [5]. McEvoy et al. address this gap with a trial comparing 2 weeks of eCPAP to standard discontinuation after achieving respiratory stability. In keeping with the author's hypothesis, pulmonary function testing revealed greater lung growth in the eCPAP group. The study's strengths include its randomised design with blinded outpatient follow-up and remarkably high participant retention. Measurement of lung function at 6 months corrected age, rather than shortly after CPAP discontinuation, likely represents a true increase in lung growth. This study also supports recently published findings that eCPAP use does not prolong hospitalisation [6]. However, several limitations in addition to those presented by the authors warrant consideration. While the authors report that there was no difference between the groups in terms of timing of oral feeds or age at discharge, we question whether additional potential adverse effects of eCPAP could be experienced, notably effects on developmental therapy participation, family bonding, or long-term neurodevelopment [7]. Additionally, there are limits to the generalisability of this study's findings. As noted in the discussion, infants with more severe respiratory disease were excluded, including those born < 24 weeks GA and those not stable on CPAP by 35 weeks PMA. Only 12% of participants were born < 29 weeks, limiting applicability to the highest-risk group for BPD and its associated complications. Given the high health care utilisation of infants born at < 24 weeks and those with more severe BPD [8, 9], investigating potential therapies to improve their lung health remains prudent. Further, while this study compared eCPAP to room air, many institutions wean from CPAP to high flow or low flow nasal cannula, which offer varying amounts of respiratory support. Whether these alternatives offer similar benefits for lung growth remains unknown. In conclusion, the study supports eCPAP as a safe, nonpharmacological approach to promoting lung growth in preterm infants. Further research should explore the optimal duration of CPAP therapy, evaluate its use in more severely ill infants, and compare it with other common weaning strategies. Longitudinal follow-up of this cohort would give exciting insight into whether extended CPAP can improve long-term respiratory health into childhood and adulthood. URL: https://ebneo.org/ebneo-commentary-extended-cpap-and-preterm-lung-growth. Mackenzie Parker: writing – original draft, writing – review and editing. Kathleen Hannan: writing – review and editing, supervision. The authors declare no conflicts of interest.