CPAP Failure in Preterm Infants With RDS

For preterm infants with RDS, guidelines recommend using CPAP as initial respiratory support.1,2* CPAP failure—often defined as the need for mechanical ventilation within 72 hours after birth—can occur. Understanding this risk enables timely treatments for preterm infants with RDS.3

*The European Consensus Guidelines on the management of RDS reflect the clinical practice standards and medications approved for use in EU hospitals; as such, certain recommendations may not be relevant to US clinical practice. US and EU patient populations and clinical practice standards are widely accepted to be distinct; therefore, there may be significant limitations to the extrapolation of certain data from EU studies to the US patient population.

Starting with CPAP may be recommended for RDS, but isn’t always enough

Clinical trials and guidelines support CPAP as a first option for respiratory management; yet the potential remains for an infant to require more intensive intervention within the first 72 hours of life.1-5*

CPAP failure does not mean failure of the infant or a failure of the clinician3,6

CPAP failure does mean that CPAP cannot provide enough respiratory support to the baby3,6

Identifying CPAP failure

See early, act early: Assessing for signs of RDS in a preterm infant’s first 2 hours of life is important to determining the need for early rescue.2*

It is important to note that early rescue may not be appropriate for all infants. Infants with RDS may vary markedly in the severity of respiratory disease, maturity, and presence of other complications, and thus it is necessary to individualize patient care.

Assess criteria

Early identification of CPAP failure should prompt consideration of early surfactant treatment.3

Act early

Early rescue has been shown to improve neonatal outcomes.7

The decision for early rescue with surfactant is multifactorial8

Multifactorial determinants: Objective measures AND Subjective signs AND Infant characteristics AND Maternal factors

See signs of CPAP failure, and avoid prolonging CPAP in nonresponders3†

Recognizing the key infant and maternal risk factors for RDS and CPAP failure is vital.6,8,9

Infant factors

Infant factors6,8,10

  • ≤32 weeks GA
  • Cesarean delivery
  • Hypothermia
  • Low birth weight
  • Apgar score ≤3 at 1 minute
  • Silverman score >2 at 2 hours
  • High oxygen requirements (eg, FiO2)
  • Clinical subjective respiratory signs (eg, labored breathing, nasal flaring)
Maternal factors

Maternal factors8,9,11-13

  • No antenatal steroid use
  • Premature rupture of membranes
  • Comorbidities (eg, hypertension, overweight/obesity, diabetes)
  • Nutritional status
  • Smoking
  • Exposure to air pollution

CPAP failure by GA in preterm infants

Studies show that CPAP failure may occur in 50% of infants born at 25 weeks GA. Though there is a decreasing risk of CPAP failure with an older GA, even at 32 weeks GA, 15% of preterm infants may fail CPAP.3

CPAP failure rate by GA3†

CPAP failure rate by gestational age: 50% at 25 weeks, 47% at 26 weeks, 48% at 27 weeks, 39% at 28 weeks, 33% at 29 weeks, 25% at 30 weeks, 19% at 31 weeks, 15% at 32 weeks

†An observational, population-based study conducted in Australia and New Zealand from 2007 to 2013. There were 19,103 premature infants born at 25 to 32 weeks GA and admitted to level 3 NICU within 60 minutes of birth. Infants were grouped by early respiratory management and categorized as CPAP success or CPAP failure. Infants on CPAP were monitored for 30 minutes. Infants on CPAP were defined as those managed initially with CPAP, with CPAP failure defined as the requirement for endotracheal intubation and mechanical ventilation within 72 hours after birth. The study faced restrictions in reporting data to a network registry, which resulted in the unavailability of detailed information on specific interventions. Results should be interpreted with caution.3

CPAP failure in preterm infants

View Study

Implementing early rescue in preterm infants with RDS6

Review studies and guidelines supporting early rescue in preterm infants with RDS who fail CPAP.

Explore Early Rescue
IMPORTANT SAFETY INFORMATION

CUROSURF® (poractant alfa) is intended for intratracheal use only. The administration of exogenous surfactants, including CUROSURF, can rapidly affect oxygenation and lung compliance. Therefore, infants receiving CUROSURF should receive frequent clinical and laboratory assessments so that oxygen and ventilatory support can be modified to respond to respiratory changes.

CUROSURF should only be administered by those trained and experienced in the care, resuscitation, and stabilization of preterm infants.

Transient adverse reactions associated with administration of CUROSURF include bradycardia, hypotension, endotracheal tube blockage, and oxygen desaturation. These events require stopping CUROSURF administration and taking appropriate measures to alleviate the condition. After the patient is stable, dosing may proceed with appropriate monitoring.

Pulmonary hemorrhage, a known complication of premature birth and very low birth-weight, has been reported with CUROSURF. The rates of common complications of prematurity observed in a multicenter single-dose study that enrolled infants 700–2000 g birth weight with RDS requiring mechanical ventilation and FiO2 ≥ 0.60 are as follows for CUROSURF 2.5 mL/kg (200 mg/kg) (n=78) and control (n=66; no surfactant) respectively: acquired pneumonia (17% vs. 21%), acquired septicemia (14% vs. 18%), bronchopulmonary dysplasia (18% vs. 22%), intracranial hemorrhage (51% vs. 64%), patent ductus arteriosus (60% vs. 48%), pneumothorax (21% vs. 36%) and pulmonary interstitial emphysema (21% vs. 38%).

INDICATION

CUROSURF® (poractant alfa) Intratracheal Suspension is indicated for the rescue treatment of Respiratory Distress Syndrome (RDS) in premature infants. CUROSURF reduces mortality and pneumothoraces associated with RDS.

Please see Full Prescribing Information.

CPAP=continuous positive airway pressure; EU=European Union; FiO2=fraction of inspired oxygen; GA=gestational age; NICU=neonatal intensive care unit; RDS=respiratory distress syndrome.

References: 1. Polin RA, Carlo WA; Committee on Fetus and Newborn; American Academy of Pediatrics. Pediatrics. 2014;133(1):156-163. 2. Sweet DG, Carnielli VP, Greisen G, et al. Neonatology. 2026:1-26. 3. Dargaville PA, Gerber A, Johansson S, et al; Australian and New Zealand Neonatal Network. Pediatrics. 2016;138(1):e20153985. 4. Stoll BJ, Hansen NI, Bell EF, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Pediatrics. 2010;126(3):443-456. 5. Dunn MS, Kaempf J, de Klerk A, et al; Vermont Oxford Network DRM Study Group. Pediatrics. 2011;128(5):e1069-e1076. 6. Dargaville PA, Aiyappan A, De Paoli AG, et al. Neonatology. 2013;104(1):8-14. 7. Stevens TP, Harrington EW, Blennow M, Soll RF. Cochrane Database Syst Rev. 2007;2007(4):CD003063. 8. Nanda D, Nangia S, Thukral A, Yadav CP. Eur J Pediatr. 2020;179(4):603-610. 9. Gyamfi-Bannerman C, Thom EA, Blackwell SC, et al; NICHD Maternal-Fetal Medicine Units Network. N Engl J Med. 2016;374(14):1311-1320. 10. Kaneshiro NK. MedlinePlus Medical Encyclopedia. Updated July 29, 2025. Accessed April 13, 2026. https://medlineplus.gov/ency/article/001563.htm 11. Ovesen P, Rasmussen S, Kesmodel U. Obstet Gynecol. 2011;118(2 Pt 1):305-312. 12. Tian T, Wang L, Ye R, Liu J, Ren A. Pregnancy Hypertens. 2020;19:131-137. 13. Terfa ZG, Nantanda R, Lesosky M, et al; IMPALA Consortium. BMJ Open. 2022;12(3):e050729.