Since its introduction in the early 1970s, continuous positive airway pressure (CPAP) has become a cornerstone of neonatal respiratory support. A 2003 review by De Paoli et\u202fal. highlighted its physiological benefits while emphasising significant uncertainty around optimal delivery, pressure, interfaces and clinical strategies.<\/p>\n\n\n\n
In 2026, nasal CPAP (nCPAP) remains central to neonatal respiratory care, but its role has evolved considerably. Advances in non-invasive ventilation (NIV), changes in delivery room practice, and a growing body of clinical evidence have reshaped how CPAP is used. Despite this progress, many of the questions raised in 2003 remain only partially resolved. This article revisits the key questions raised in 2003 and summarises what we now know, alongside ongoing uncertainties.<\/p>\n\n\n\n
The physiological principles underpinning CPAP have not changed. Its ability to maintain functional residual capacity, improve oxygenation and reduce work of breathing continues to form the basis of its clinical utility.\u00b9 Over the past two decades, however, the context in which CPAP is used has shifted markedly.<\/p>\n\n\n\n
Modern neonatal practice now prioritises non-invasive respiratory support, with CPAP frequently used as the initial modality for preterm infants with respiratory distress syndrome (RDS). This approach reflects increasing recognition that avoiding invasive mechanical ventilation may reduce ventilator-associated lung injury and improve outcomes. Contemporary reviews confirm that non-invasive ventilation strategies, with CPAP as a cornerstone, have become standard care in many settings.\u00b2<\/p>\n\n\n\n
Moreover, CPAP is no longer simply a post-extubation support tool. It is now widely initiated in the delivery room for very preterm infants, often as part of a broader strategy that includes early stabilisation and selective surfactant administration.<\/p>\n\n\n\n
Evidence accumulated since 2003 continues to support the effectiveness of nasal CPAP across a range of neonatal populations. Observational data demonstrates high treatment success rates, with reports of improvement in respiratory distress and oxygenation within the first 24 hours of therapy.\u00b3<\/p>\n\n\n\n
Importantly, outcomes appear to be influenced not only by the device itself but by how CPAP is implemented. Studies evaluating structured protocols, particularly those incorporating early use of bubble CPAP, have shown reductions in intubation rates and improvements in survival free from severe bronchopulmonary dysplasia (BPD).\u2074 These findings highlight the importance of system-level approaches, including staff training, protocolisation and early initiation.<\/p>\n\n\n\n
In this context, CPAP is now considered a core component of lung-protective strategies in neonatology, complementing antenatal corticosteroids and surfactant therapy.<\/p>\n\n\n\n
Uncertainty around the optimal interface was a key issue in 2003 and remains relevant. Short binasal prongs continue to be widely used in clinical practice, reflecting their ability to deliver relatively stable airway pressure.\u00b9 However, newer interfaces, including nasal masks and hybrid systems, are increasingly utilised.<\/p>\n\n\n\n
Recent research has focused on the prevention of nasal trauma, a recognised complication of CPAP. A systematic review published in 2025 identified differences in nasal injury rates between masks and prongs, emphasising the role of interface selection, rotation strategies and regular skin assessment in minimising harm.\u2075 While no single interface has been shown to be unequivocally superior, there is growing consensus that careful device management is as important as device choice.<\/p>\n\n\n\n
Optimal CPAP pressure remains uncertain. While 5\u20138\u202fcmH\u2082O is commonly used, higher pressures may be required in infants with reduced lung compliance.\u00b9 A Cochrane review found insufficient evidence to determine an optimal pressure strategy, reflecting ongoing variability in practice.\u2076<\/p>\n\n\n\n
Bubble CPAP continues to gain prominence due to its simplicity and physiological effects, including oscillatory pressure delivery that may improve gas exchange.\u2077 Implementation studies demonstrate improved respiratory outcomes and reduced mortality when used within structured care pathways.\u2074<\/p>\n\n\n\n
One of the recognised physiological consequences of CPAP is the passage of air into the gastrointestinal tract, leading to gastric distension, often termed \u201cCPAP belly syndrome\u201d. This is generally benign but may impair diaphragmatic excursion and contribute to feeding intolerance if significant.\u00b9\u00b9<\/p>\n\n\n\n
The routine use of orogastric or nasogastric tubes for gastric decompression<\/strong>, sometimes informally referred to as high-flow gastric venting, has become an important adjunct to CPAP therapy. Placement of a suitably sized orogastric tube allows continuous or intermittent venting of swallowed air, helping to reduce abdominal distension and maintain respiratory efficiency.<\/p>\n\n\n\n Quality improvement and observational data suggest that proactive gastric decompression can reduce feeding intolerance and optimise respiratory mechanics, particularly in extremely preterm infants receiving CPAP.\u00b9\u00b2 Additionally, orogastric tubes are often preferred over nasogastric tubes in this context, as nasal tubes may increase airway resistance and work of breathing.\u00b9\u00b2<\/p>\n\n\n\n Although high-quality comparative trials are limited, this practice is widely accepted as part of supportive care during CPAP and reflects an increased understanding of the interaction between respiratory support and gastrointestinal physiology.<\/p>\n\n\n\n Since 2003, the landscape of neonatal respiratory support has expanded considerably, with CPAP now sitting alongside several alternative NIV modalities.<\/p>\n\n\n\n Nasal intermittent positive pressure ventilation (NIPPV) has been extensively studied. Updated Cochrane evidence suggests that NIPPV probably reduces the risk of respiratory failure and the need for reintubation when compared with CPAP, particularly following extubation.\u2078 However, more recent real-world data indicate that CPAP can achieve comparable reintubation rates when optimised, even if short-term treatment failure is higher.\u2079 This suggests that CPAP remains a valid and widely accessible option, particularly when used within well-defined care pathways.<\/p>\n\n\n\n High-flow nasal cannula (HFNC) has also emerged as an alternative form of support. Meta-analyses indicate that while HFNC may offer advantages in terms of reduced nasal trauma and improved comfort, it may be associated with higher rates of treatment failure compared with CPAP in some populations.\u00b9\u2070 Consequently, HFNC is often used as a step-down therapy rather than a primary modality in very preterm infants.<\/p>\n\n\n\n Emerging technologies such as neurally adjusted ventilatory assist and nasal high-frequency ventilation are under investigation, but evidence remains limited and insufficient to support routine use at present.\u00b2<\/p>\n\n\n\n One of the key uncertainties identified in 2003 was whether CPAP should be used from birth. Current evidence supports early CPAP as part of an initial stabilisation strategy for preterm infants, reducing exposure to mechanical ventilation.\u00b2<\/p>\n\n\n\n This approach is often combined with selective or minimally invasive surfactant administration. While consistent reductions in BPD have not been demonstrated across all studies, early CPAP has contributed to a broader shift towards less invasive respiratory care.<\/p>\n\n\n\n Nasal CPAP is generally considered safe, but complications remain an important consideration. Nasal injury continues to be the most common adverse effect, alongside less frequent issues such as air leak and gastric distension.\u00b9<\/p>\n\n\n\n Many practical aspects of CPAP management remain guided by experience rather than high-quality evidence. These include criteria for defining treatment failure, optimal timing of escalation, and strategies for weaning. Recent studies suggest that duration of CPAP may influence feeding outcomes and length of hospital stay, but further research is needed to guide practice.\u00b9\u00b9<\/p>\n\n\n\n Over the past two decades, nasal CPAP has evolved from a supportive therapy to a central component of modern neonatal respiratory care. Its role within an NIV-first strategy represents a major shift in clinical practice, with increasing emphasis on early use, protocolised care and avoidance of invasive ventilation.<\/p>\n\n\n\n Nevertheless, the field continues to be characterised by important unanswered questions. As in 2003, uncertainty remains regarding optimal pressure, flow, interface selection and weaning strategies. Future research will need to address these gaps while also evaluating emerging technologies and refining existing approaches.<\/p>\n\n\n\n Nasal CPAP remains both an established and evolving therapy, requiring a combination of evidence-based practice and clinical expertise to achieve the best outcomes for neonates.<\/p>\n\n\n\n Since its introduction in the early 1970s, continuous positive airway pressure (CPAP) has become a cornerstone of neonatal respiratory support. A 2003 review by De Paoli et\u202fal. highlighted its physiological benefits while emphasising significant uncertainty around optimal delivery, pressure, interfaces and clinical strategies. In 2026, nasal CPAP (nCPAP) remains central to neonatal respiratory care, but […]<\/p>\n","protected":false},"author":4,"featured_media":52602,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"categories":[18],"tags":[],"class_list":["post-53448","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-neonatology"],"acf":[],"_links":{"self":[{"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/posts\/53448","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/comments?post=53448"}],"version-history":[{"count":1,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/posts\/53448\/revisions"}],"predecessor-version":[{"id":53449,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/posts\/53448\/revisions\/53449"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/media\/52602"}],"wp:attachment":[{"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/media?parent=53448"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/categories?post=53448"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/campusvygon.com\/uk\/wp-json\/wp\/v2\/tags?post=53448"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}CPAP in relation to other non-invasive modalities<\/h2>\n\n\n\n
Early CPAP and surfactant strategies<\/h2>\n\n\n\n
Complications and ongoing challenges<\/h2>\n\n\n\n
Conclusion<\/h2>\n\n\n\n
References<\/h2>\n\n\n\n
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<\/h2>\n","protected":false},"excerpt":{"rendered":"