We read with interest the communication by Patole, et al.(1). Definitely the adminis-tration of antenatal glucocorticoids and availability of Hudson-Prongs (HP) conti-nuous positive airway pressure(CPAP) are remarkable breakthroughs in management of preterm babies and have played a role in reducing the need for ventilation. Our neonatal set up is very similar to the authors and we would like to share our experience of a similar case. This baby was the second of twins delivered by cesarean section in view of fetal decelerations at 30 week gestation and weighed 1245 grams. He was transferred from operation theater to newborn care with CPAP support by Neopuff resuscitaire and was put on 5 cm CPAP in 28% FiO2 (fraction of oxygen in inspired air). Chest radiograph at six hours of life was typical of hyaline membrane disease. At about 24 hours of birth, he deteriorated and oxygen requirement rose to CPAP of 6 cm with 40% FiO2 and upto 55% in next four hours. We were in a dilemma at this stage-whether to initiate ventilation and give surfactant or give a watchful trial of 7 cm CPAP. After transillumination for possible pneumothorax was negative, we chose the latter option. The other measures adopted included using bigger prongs (so as to have a more snug fit and avoid leak), keeping in prone position and putting a rolled soft towel under neck. The former helps by better aeration of dependent regions of the lungs thus improving ventilation/perfusion ratios(2) and the latter by splinting the upper airway. Within three hours FiO2 could be weaned to 35% and CPAP to 5 cm, thus obviating the need for ventilation. This improvement was sustained and the baby could be rapidly weaned off oxygen support. CPAP is a critical component of therapy in RDS where loss of surface area is the main denominator and it helps by improving alveolar recruitment. Currently, a multicentric trial (coordinated from Melbourne) is underway in Australia, randomizing infants to CPAP or intubation, the primary outcome being the incidence of Chronic Lung Disease. What would be of interest is to identify variables, which will help recognize babies likely to fail trial of CPAP, so that ventilation could be initiated in them straight away.

Arvind Sehgal,
Jacqueline Stack,
Department of Newborn Care,
Liverpool Hospital,
South Western Sydney Area Health Service,
Sydney, New South Wales, Australia.

1. Patole SK, Mcglone L, Hares D. Improving oxygenation in preterm neonates with respiratory distress. Indian Pediatr 2002; 40: 376.

2. Martin RJ, Herrel N, Rubin D, Fanaroff A. Effect of supine and prone positions on arterial oxygen tension in the preterm infant. Pediatrics 1979; 63: 528-531.