Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, MD,A Myra H

Home , Resuscitation

Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, MD,a Myra H. Wyckoff, MD,a Vishal Kapadia, MD,a Mambarambath Jaleel, MD,a Venkatakrishna Kakkilaya, MD,a L. Steven Brown, MS,b David B. Nelson, MD,c Luc P. Brion, MDa

BACKGROUND: In 2011, the Neonatal Resuscitation Program (NRP) added consideration of abstract continuous positive airway pressure (CPAP) for spontaneously breathing infants with labored breathing or hypoxia in the delivery room (DR). The objective of this study was to determine if DR-CPAP is associated with symptomatic pneumothorax in infants 35 to 42 weeks’ gestational age. METHODS: We included (1) a retrospective birth cohort study of neonates born between 2001 and 2015 and (2) a nested cohort of those born between 2005 and 2015 who had a resuscitation call leading to admission to the NICU and did not receive positive-pressure ventilation. RESULTS: In the birth cohort (n = 200 381), pneumothorax increased after implementation of the 2011 NRP from 0.4% to 0.6% (P , .05). In the nested cohort (n = 6913), DR-CPAP increased linearly over time (r = 0.71; P = .01). Administration of DR-CPAP was associated with pneumothorax (odds ratio [OR]: 5.5; 95% conﬁdence interval [CI]: 4.4–6.8); the OR was higher (P , .001) in infants receiving 21% oxygen (OR: 8.5; 95% CI: 5.9–12.3; P , .001) than in those receiving oxygen supplementation (OR: 3.5; 95% CI: 2.5–5.0; P , .001). Among those with DR-CPAP, pneumothorax increased with gestational age and decreased with oxygen administration. CONCLUSIONS: The use of DR-CPAP is associated with increased odds of pneumothorax in late- preterm and term infants, especially in those who do not receive oxygen in the DR. These ﬁndings could be used to clarify NRP guidelines regarding DR-CPAP in late-preterm and term infants.

aDivision of Neonatal-Perinatal Medicine, Department of Pediatrics and cDivision of Maternal-Fetal Medicine, WHAT’S KNOWN ON THIS SUBJECT: Continuous Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, Texas; and bParkland Health positive airway pressure (CPAP) is a risk factor for and Hospital System, Dallas, Texas pneumothorax. New Neonatal Resuscitation Program Dr Smithhart conceptualized and designed the study, merged the spreadsheets of the 2 databases, guidelines included CPAP as a possible corrective and wrote the ﬁrst draft of the manuscript; Drs Wyckoff, Jaleel, Kapadia, Nelson, and Kakkilaya measure for spontaneously breathing infants who conceptualized and designed the study; Mr Brown conducted statistical analyses; Dr Brion have labored breathing or persistent cyanosis. conceptualized and designed the study and conducted statistical analyses; and all authors WHAT THIS STUDY ADDS: Among late-preterm and participated in the interpretation of the data, critically reviewed the revisions, approved the ﬁnal manuscript as submitted, and agree to be accountable for all aspects of the work. term infants, pneumothorax increased after implementation of the new Neonatal Resuscitation DOI: https://doi.org/10.1542/peds.2019-0756 Program guidelines. Delivery room CPAP was Accepted for publication May 28, 2019 associated with pneumothorax. The odds ratio was Address correspondence to Luc P. Brion, MD, Division of Neonatal-Perinatal Medicine, Department of higher in infants receiving 21% oxygen than in those Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, STOP 9063, receiving oxygen supplementation. Dallas, TX 75390-9063. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Smithhart W, Wyckoff MH, Kapadia V, et al. Delivery Room Continuous Positive Airway Pressure and Copyright © 2019 by the American Academy of Pediatrics Pneumothorax. Pediatrics. 2019;144(3):e20190756

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 3, September 2019:e20190756 ARTICLE The use of delivery room (DR) preterm infants that is caused by RDS with short-term PPV with a self- continuous positive airway pressure or retained lung fluid (both inflating bag. Only the NICU (CPAP) has increased in preterm associated with decreased lung resuscitation team can provide CPAP infants in recent years,1 likely compliance). However, in term or positive end-expiratory pressure to because of lower risk of the combined infants, RDS prevalence is low. newborns in the DR. Facemask CPAP outcome of death or Grunting, nasal flaring, or retractions is provided via NeoPuff T-piece bronchopulmonary dysplasia, as may result from diagnoses for which resuscitator. CPAP is typically started compared with DR endotracheal DR-CPAP administration is not at 5 cm H2O and further escalated to intubation.2,3 DR intubation a proven therapy, such as fetal a maximum of 8, if needed, in the DR decreased in preterm infants at acidemia, perinatal asphyxia, or later in the NICU, on the basis of Parkland Health and Hospital System pulmonary hypertension, chest radiograph findings and oxygen (PHHS) as well,4 coinciding with pneumothorax, congenital requirement. PHHS adopted the NRP participation (2005–2009) in the diaphragmatic hernia, polycythemia, guidelines including DR-CPAP in Surfactant, Positive Pressure, and fever, sepsis, or hypoglycemia.14,15 spontaneously breathing infants with Oxygenation Randomized Trial Therefore, we hypothesized that in respiratory distress or hypoxia in July (SUPPORT), in which researchers late-preterm and term infants, the use 2011. Criteria for NICU admission are compared DR intubation to DR- of DR-CPAP would be associated with listed online (Supplemental CPAP.5 New guidelines were increased frequency of symptomatic Information). published in 2010 and implemented pneumothorax. by the Neonatal Resuscitation Data Sources Program (NRP) in 2011, which METHODS Data were obtained from the included CPAP as a possible Parkland neonatal resuscitation and corrective measure for spontaneously Design NICU databases. The neonatal breathing infants without apnea, This was a retrospective birth cohort resuscitation database is gasping, or heart rate ,100 beats per study with a nested cohort. a compilation of data since 2005 minute who have labored breathing pertaining to DR resuscitation of or persistent cyanosis, regardless of Patients newborns who are admitted to the gestational age (GA).6,7 Entry criteria for the birth cohort NICU as well as data at the time of admission to the NICU. The Parkland CPAP improves oxygenation in included infants 35 to 42 weeks’ GA NICU database provides data during preterm infants with respiratory born at PHHS between 2001 and their NICU stay. distress syndrome (RDS).8 CPAP may 2015. To further assess the effects of also improve functional residual DR-CPAP, we selected a nested cohort capacity, respiratory work, and gas of at-risk infants (1) treated by Outcome Variables exchange.9 The effect of positive a resuscitation team (which could The primary outcome of the birth pressure on lung volume increases provide DR-CPAP), (2) with extensive cohort was the change in percentage with lung elasticity, which is directly available information (available in of pneumothorax after related to GA, and decreases with those born between 2005 and 2015 implementation of the new NRP chest wall elasticity, which is who were admitted to the NICU), and guidelines. inversely related to GA.7,10 The (3) excluding those who received DR The primary outcome of the nested amount of pressure required to cause positive-pressure ventilation (PPV). cohort was the odds ratio (OR) of lung rupture decreases with pneumothorax of infants who increasing GA because of increased Setting received DR-CPAP versus those who distensibility and decreased surface At PHHS, deliveries for infants 35 to did not receive DR-CPAP. Secondary tension.11 The association between 42 weeks’ GA are typically attended outcomes included the use of DR- CPAP and air leak syndrome has been by a provider from the newborn CPAP and the comparison of OR of a concern in neonatal literature.12 In nursery who may use PPV without pneumothorax with CPAP in infants the Continuous Positive Airway positive end-expiratory pressure, receiving 21% oxygen in the DR Pressure or Intubation at Birth using a self-inflating bag. The PHHS versus OR in those receiving oxygen (COIN) trial, increased air leak in DR- NICU resuscitation team is called for supplementation. CPAP versus DR intubation may have infants 35 to 42 weeks’ GA at high resulted from a higher level of CPAP risk for needing resuscitation (eg, than in similar studies.4,13 CPAP is an malformations), fetal compromise (ie, Approval appropriate DR therapy for most nonreassuring fetal heart tones), or This study was approved by the hypoxia or labored breathing in poor respiratory effort not resolving University of Texas Southwestern

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 SMITHHART et al Medical Center Institutional Review Board and by PHHS.

Statistical Analysis Continuous variables are presented as mean (SD) or median (interquartile range). Changes over time (with participation in SUPPORT and after implementation of the new NRP guidelines) were analyzed either by statistical process control (P control chart) by using QI Macros for Excel (KnoWare International, Denver, CO) if values were stable or by time series analysis to analyze significance of trends. Other statistical analyses were conducted by using SPSS version 23 (IBM, Inc, FIGURE 1 Armonk, NY) or SAS version 14.2 Study participant flow diagram showing the birth cohort (infants 35–42 weeks’ GA born in – – ’ – (SAS Institute, Inc, Cary, NC) for 2- 2001 2015) and the nested cohort (infants 35 42 weeks GA born in 2005 2015 who had a DR resuscitation team call, did not receive PPV in the DR, and were admitted to the NICU). O , oxygen. tailed tests, with P , .05 considered 2 significant. Continuous variables were included all variables available in the To detect a 25% increase in analyzed by using Student t test, DR (excluding CPAP) and soon after frequency of pneumothorax in the Mann-Whitney test, or time series NICU admission that reached birth cohort from a baseline of 0.4% analysis. Dichotomous outcomes were significance on forward stepwise with a statistical power of 0.9, a total analyzed by x2 analysis (exact test regression as well as the change in n of 9030 patients in each group was followed by pairwise comparisons practice recommended by the NRP.17 needed, using x2 analysis. Sample size with Bonferroni correction, as Each treated neonate was matched by analysis for the logistic regression in appropriate) and Cochran-Mantel- using a SAS macro18 with 2 controls the nested cohort was sufficient to Haenszel test. whose propensity scores differed have at least 10 subjects with Because this was a retrospective from the treated infant by ,0.01 (ie, pneumothorax per variable included observational study, the association caliper matching).19 Imbalance of in the logistic regression analysis. between DR-CPAP and pneumothorax covariates was assessed by the could have resulted from bias standardized difference, using a SAS RESULTS because of unequal distribution of macro.17,20 Birth Cohort prognostic factors between patients Fourth, instrumental variable analysis exposed (treated) or not exposed was used to control for unmeasured The birth cohort included 200 381 (controls) to DR-CPAP. Four approaches – 16 confounding. A valid instrumental neonates born 2001 2015 (Fig 1). were used to adjust for bias. variable is a variable that (1) is The percentage of symptomatic First, stepwise logistic regression independent of the unmeasured pneumothorax, initially stable, analysis was conducted to adjust for confounding, (2) affects the increased progressively after confounders. treatment, and (3) affects the implementing the new guidelines outcome only indirectly through its (Fig 2). The average percentage of Second, the analysis was adjusted for effect on the treatment.21 Epoch pneumothorax increased from 0.38% DR oxygen administration by testing (defined by calendar year and change before implementation (561 out of for an additive interaction between in guidelines) was selected as an 148 591) to 0.56% (292 out of DR-CPAP and DR oxygen. instrumental variable because of 51 790) after implementation of the Third, propensity score analysis was changes in DR-CPAP use over time. new NRP guidelines (P , .05). conducted to reduce imbalance Imbalance of covariates was assessed between treated neonates and by the multivariate imbalance Nested Cohort controls on many covariates merged coefficient (ranging from 0 to 1, Among 9304 neonates born at 35 into a single variable, the propensity representing perfect balance and to 42 weeks’ GA in 2005–2015 who score. As recommended by Austin, the imbalance, respectively), using the GI had a DR resuscitation team call and propensity score for pneumothorax SAS macro.21 were admitted to the NICU, 6913

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 3, September 2019 3 NRP guidelines beyond the level during SUPPORT (Fig 4). In contrast, DR-CPAP in neonates receiving 21% oxygen increased in 2011 after implementing the new NRP guidelines (Fig 4).

Association of CPAP With Pneumothorax Among 6913 neonates, the frequency of pneumothorax was 3.7% among those who did not receive DR-CPAP and 16.9% among those who received DR-CPAP (number needed to harm: 8) (Table 2). Administration of DR-CPAP was significantly associated with pneumothorax (OR: 4.6; 95% confidence interval [CI]: 3.6–6.0) in fi FIGURE 2 bivariate analysis. This was con rmed Evolution of the percentage of neonates with pneumothorax in the birth cohort. The graph shows in multivariate analyses year on the x-axis and the percentage of neonates 35 to 42 weeks’ GA with pneumothorax on the (Supplemental Tables 3–6). Both y-axis. CL, center line; LCL, lower control limit; UCL, upper control limit. instrumental variable and propensity score analyses substantially reduced (nested cohort) did not receive PPV CPAP, there was a lower proportion imbalance of covariates between (Fig 1). of girls and Hispanics and lower treated patients and controls (Supple Apgar scores (Table 1). mental Tables 4 and 5). In the nested cohort, infants who The OR of pneumothorax associated received DR-CPAP had significantly DR-CPAP use increased linearly over with CPAP was higher (P , .001) in higher proportions of placental time (r = 0.71, P = .01) (Fig 3). DR- infants receiving 21% oxygen (OR: abruption, meconium-stained CPAP in neonates requiring oxygen 8.5; CI: 5.9–12.3; P , .001) than in amniotic fluid, cesarean delivery, and supplementation in the DR increased those receiving oxygen surfactant administration compared during the SUPPORT trial, then supplementation (OR: 3.5; CI: 2.5–5.0; with those who did not receive DR- transiently decreased and did not P , .001) in bivariate analysis (Fig 1). CPAP. Among infants receiving DR- increase after implementing the new Similar results were obtained in multivariate analyses (Supplemental TABLE 1 Perinatal Characteristics of Infants 35 to 42 Weeks’ GA in the Nested Cohort Tables 5, 7, and 8). The frequency of DR-CPAP No DR-CPAP P pneumothorax was not significantly n = 1001 n = 5912 associated with the level of CPAP (P = .68). Preeclampsia, n (%) 159 (16) 815 (14) .09 Placental abruption, n (%) 12 (1.2) 28 (0.5) .01 Meconium-stained fluid, n (%) 285 (29) 1053 (18) ,.001 Other Outcomes Cesarean delivery, n (%) 657 (66) 3124 (53) ,.001 Pulmonary interstitial emphysema Female, n (%) 416 (42) 2762 (47) .003 occurred in 8 out of 6913 patients: 3 Race and ethnicity, n (%) .04 Hispanic 725 (72)a 4526 (77)a out of 1001 on CPAP versus 5 out of African-American non-Hispanic 162 (16) 845 (14) 5912 without CPAP (P = .01). White non-Hispanic 78 (8) 377 (6) Other 36 (4) 164 (3) Among 388 patients with GA, mean 6 SD, wk 38 6 2386 2 .89 pneumothorax, 7.9% received either Birth wt, mean 6 SD, g 3159 6 669 3123 6 729 .13 thoracocentesis or thoracostomy Intrauterine growth restriction, n (%) 21 (2.1) 264 (4.5) ,.001 (Table 2). The percentage of – – , Apgar 1 min, median (IQR) 8 (7 8) 8 (8 8) .001 treatment was similar in those with Apgar 5 min, median (IQR) 8 (8–9) 9 (9–9) ,.001 Surfactant administration, n (%) 18 (1.8) 19 (0.3) ,.001 versus those without DR-CPAP. The frequency of treatment was 7 out of Student t test, Mann-Whitney test, or x2 analysis (exact test followed by pairwise comparisons with Bonferroni correction, as appropriate. IQR, interquartile range. 210 (3%) in those without a Indicates pairwise comparisons that reached significance. respiratory support at the time of

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 SMITHHART et al variable analysis and propensity score analysis. The odds of DR- CPAP–associated pneumothorax increased with increasing GA and decreased with oxygen requirement, suggesting that the risk of CPAP- induced pneumothorax is higher in more-mature lungs with less underlying disease.

The interaction between oxygen administration and DR-CPAP, as well as the increasing odds of pneumothorax with increasing GA among neonates receiving DR-CPAP, is consistent with Adler’s data in which an increased risk of pneumothorax in neonates with FIGURE 3 higher lung compliance and Evolution of the use of CPAP among neonates in the nested cohort. The graph shows year on the lower chest wall compliance was x-axis and the percentage of neonates who received CPAP on the y-axis. shown.10 Moreover, our data are consistent with previous studies in diagnosis versus 24 out of 178 (13%) implementation of the new NRP which an association between DR- in those on positive airway pressure, guidelines. In a nested cohort, we CPAP and pneumothorax in late- P , .001. found a progressive increase in DR- preterm and term neonates was shown. Among infants given DR-CPAP, CPAP in all infants, regardless of pneumothorax increased with increasing whether they needed oxygen In a large Canadian retrospective GA and was higher in boys and lower in supplementation or not. DR-CPAP cohort study of 71 237 infants, it was infants who received oxygen in the DR was associated with increased odds of found that CPAP was protective from (Supplemental Table 9). pneumothorax. The OR of developing pneumothorax in early- pneumothorax with CPAP in neonates preterm neonates but was a risk receiving DR-CPAP and 21% oxygen DISCUSSION factor for pneumothorax in moderate- was 3 times as high as in those to-late-preterm and term neonates.22 We present a large birth cohort study receiving DR-CPAP with in which an increase in supplemental oxygen. Similar results In 2015, Hishikawa et al23 found that pneumothorax was shown after were obtained by instrumental implementation of new Japanese

FIGURE 4 Control charts of use of CPAP in the DR versus oxygen administration in the DR in the nested cohort. The graphs show year on the x-axis and the percentage of neonates who received CPAP on the y-axis. A, Oxygen administration in the DR. B, Room air in the DR. CL, center line; LCL, lower control limit; UCL, upper control limit.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 3, September 2019 5 TABLE 2 Pneumothorax by Epoch Versus Continuous Positive Pressure and Oxygen Administration in the DR in the Nested Cohort Epoch Room Air Oxygen Total No DR-CPAP DR-CPAP No DR-CPAP DR-CPAP No DR-CPAP DR-CPAP No. patients with pneumothorax out of total no. patients (%) 2005 12 out of 251 (5) 0 out of 1 (0) 9 out of 238 (4) 6 out of 52 (12) 21 out of 489 (4) 6 out of 53 (11) 2006 5 out of 280 (2) — 10 out of 260 (4) 8 out of 60 (13) 15 out of 540 (3) 8 out of 60 (13) 2007 29 out of 495 (6) 0 out of 1 (0) 9 out of 50 (18) 8 out of 49 (16) 38 out of 545 (7) 8 out of 50 (16) 2008 17 out of 478 (4) 0 out of 2 (0) 3 out of 45 (7) 12 out of 72 (17) 20 out of 523 (4) 12 out of 74 (16) 2009 24 out of 504 (5) 0 out of 1 (0) 3 out of 28 (11) 5 out of 48 (10) 27 out of 532 (5) 5 out of 49 (10) 2010 12 out of 423 (3) 2 out of 16 (13) 2 out of 67 (3) 13 out of 90 (14) 14 out of 490 (3) 15 out of 107 (14) 2011aa 3 out of 186 (2) 1 out of 15 (7) 0 out of 30 (0) 2 out of 20 (10) 3 out of 216 (1) 3 out of 35 (9) 2011ba 12 out of 258 (5) 3 out of 18 (17) 3 out of 50 (6) 10 out of 36 (28) 15 out of 308 (5) 13 out of 54 (24) 2012 15 out of 538 (3) 8 out of 39 (21) 4 out of 81 (5) 2 out of 66 (3) 19 out of 619 (3) 10 out of 105 (10) 2013 17 out of 482 (4) 11 out of 45 (24) 4 out of 82 (5) 22 out of 110 (20) 21 out of 564 (4) 33 out of 155 (21) 2014 10 out of 432 (2) 9 out of 34 (27) 3 out of 86 (4) 13 out of 97 (13) 13 out of 518 (3) 22 out of 131 (17) 2015 9 out of 510 (2) 19 out of 59 (32) 3 out of 58 (5) 16 out of 69 (23) 12 out of 568 (2) 35 out of 128 (27) 2005–2015 165 out of 4837 (3) 53 out of 231 (23) 53 out of 1075 (5) 117 out of 770 (15) 218 out of 5912 (4) 170 out of 1001 (17) No. patients needing thoracocentesis or thoracostomy out of total no. with pneumothorax (%) 2005–2015 8 out of 165 (5) 7 out of 53 (13) 7 out of 53 (13) 9 out of 117 (8) 15 out of 218 (7) 16 out of 170 (9) —, not applicable. a 2011a and 2011b are before and after implementation of the new NRP guidelines, respectively. resuscitation guidelines including DR- versus free-flow oxygen reduced Third, we evaluated the interaction CPAP was associated with increased the duration and severity of between oxygen requirement and pneumothorax in early-term infants respiratory distress.25 In another DR-CPAP in regards to probability but not in those born beyond 38 study among infants with of pneumothorax. This is, to weeks. The association between meconium aspiration syndrome, our knowledge, the only study in guideline implementation and CPAP reduced the need for which this interaction has been pulmonary air leak disappeared mechanical ventilation.26 In the examined. by adjusting for DR mask CPAP.23 third study among infants born at .30 weeks’ GA with respiratory There were several limitations to our In 2017, Clevenger and Britton24 distress, CPAP versus headbox study. First, this was a retrospective reported increased odds of oxygen administration reduced the analysis, and randomization was not pneumothorax with DR-CPAP need for up-transfer of infants with possible. This weakness was in part (adjusting for GA) both in a case- respiratory distress in nontertiary mitigated by using 4 methods: logistic control study and in a later cohort centers. There was a clinically regression, analysis adjusted for DR study in term neonates. However, relevant but not statistically oxygen administration, analysis fi because controls of the cohort study significant increase in strati ed for epoch as instrumental were healthy, the possibility of pneumothorax.27 variable, and propensity score 17 selection bias or confounders was not analysis. Secondly, it was impossible taken into account in the analysis, Our study has several strengths that to distinguish whether some of the suggesting a possible overestimation distinguish it from previous studies in pneumothoraxes noted on chest of the association between DR-CPAP which researchers have evaluated radiograph were in fact spontaneous and pneumothorax.24 DR-CPAP and pneumothorax. First, pneumothoraxes present before both the birth cohort and the nested application of DR-CPAP. Third, data on In at least 3 randomized trials, cohort had a large sample size. infants who had a resuscitation team researchers have shown the benefitof Second, analysis of the association call but were not admitted to the NICU CPAP in late-preterm infants and of pneumothorax with CPAP was are not available because these infants term infants with respiratory done in a nested cohort of high-risk are not included in the resuscitation distress and oxygen requirement in neonates, excluding those who database; therefore, the frequency of the NICU. In one study in neonates received PPV in the DR, thereby pneumothorax among all infants who with transient tachypnea of the avoiding attribution of had a resuscitation team call could not newborn, DR-CPAP using a pneumothorax to CPAP in be assessed. Fourth, the true overall a T-piece–based infant resuscitator a patient who also had received PPV. incidence of pneumothorax in this

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 SMITHHART et al cohort is not known because chest CPAP plays in the treatment of term ABBREVIATIONS radiograph was obtained only in infants with oxygen requirement in symptomatic neonates. the DR. CI: confidence interval CPAP: continuous positive airway With the findings from our study, 2 pressure clinical implications are suggested. DR: delivery room First, caution should be applied ACKNOWLEDGMENTS GA: gestational age regarding providing DR-CPAP, We thank Patti Jeannette Burchfield, NRP: Neonatal Resuscitation especially in the term population. RN, for her work in collecting and Program Second, the use of CPAP should be re- extracting data for the NICU database. OR: odds ratio evaluated as therapy for grunting, We thank Lucy Christie, RN, and Anita PHHS: Parkland Health and nasal flaring, or tachypnea in infants Thomas, RN, for their work in Hospital System 35 to 42 weeks’ GA without an collecting and extracting data for the PPV: positive-pressure oxygen requirement in the DR. These resuscitation database. Their ventilation findings could be used to clarify NRP expertise made this project possible. RDS: respiratory distress guidelines regarding the use of We also thank Robert Haley, MD, for syndrome DR-CPAP. Further studies may his help with propensity score be necessary to clarify the role DR- analysis.

FINANCIAL DISCLOSURE: The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conﬂicts of interest to disclose. COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1720.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 SMITHHART et al Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, Myra H. Wyckoff, Vishal Kapadia, Mambarambath Jaleel, Venkatakrishna Kakkilaya, L. Steven Brown, David B. Nelson and Luc P. Brion Pediatrics originally published online August 9, 2019;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/08/07/peds.2 019-0756 References This article cites 20 articles, 4 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/08/07/peds.2 019-0756#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://www.aappublications.org/cgi/collection/fetus:newborn_infant_ sub Neonatology http://www.aappublications.org/cgi/collection/neonatology_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 24, 2021 Delivery Room Continuous Positive Airway Pressure and Pneumothorax William Smithhart, Myra H. Wyckoff, Vishal Kapadia, Mambarambath Jaleel, Venkatakrishna Kakkilaya, L. Steven Brown, David B. Nelson and Luc P. Brion Pediatrics originally published online August 9, 2019;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2019/08/07/peds.2019-0756

Data Supplement at: http://pediatrics.aappublications.org/content/suppl/2019/08/07/peds.2019-0756.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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