1. CATS Justine Iris Yap, MD Lia May Banting-Tapangco, MD 25 September 2010

2. Clinical Scenario: • OA was born PT 32wks by PA, 1300g SGA, LBW, del via LSCS, LBB AS 5,6 • Upon birth patient was limp, cyanotic HR<100  PPV was done • After 30s, HR140, RR70, w/ some movement, acrocyanotic, w/ note of alar flaring & grunting • Patient was placed on 100% O2 hood but there was persistence of tachypnea, alar flaring & grunting • Pxt was intubated ET2.5L7 and hooked to MV

3. Clinical Question Among infants with respiratory distress syndrome treated in non-tertiary care, will the use of CPAP therapy reduce the number of transfer to a NICU?

4. Citation

5. P: Infants <24 hours of age with clinical signs of respiratory distress I: CPAP therapy vs headbox oxygen treatment O: uptransfer or treatment failure M: Randomized Controlled Trial

6. Study Characteristics • Patients included • All infants < 24 hours of age with clinical signs of respiratory distress who required >30% oxygen in a headbox to maintain O2 saturations of >/= 94% for > 30 minutes

7. Study Characteristics • Interventions Compared • CPAP therapy versus headbox oxygen therapy

8. Study Characteristics • Outcomes Monitored • Uptranser or Treatment Failure • Parameters of treatment failure: FiO2 (>/= 60% for the headbox group or >/= for the CPAP group) CO2 level and pH (CO2 of >60 mmHg or pH <7.25 in 2 successive gas samples >/= 1 hour apart • Nursery Length of stay • Length of oxygen treatment

9. Validity Criteria • Were patients randomized • YES. Random allocation was computer-generated • Was randomization concealed? • No • Were the patients analyzed in the groups to which they were randomized • YES

10. Validity Criteria • Were patients in the treatment and control groups similar at baseline? • YES • Were patients aware of group allocation? • YES • Were the clinicians aware of group allocation? • YES

11. Validity Criteria • Were outcome assessors aware of group allocation? • YES • Was follow-up complete? • YES

12. Results • Risk in Control • Uptransfer in control/N patients in control 54/149 = 0.36 • Treatment failure in control/N patients in control 47/149 = 0.31 • Risk in Treatment • Uptransfer in treatment/N patients in treatment 34/151 = 0.22 • Treatment failure in treatment/N patients in treatment 30/151 = 0.20

13. Results • Absolute Risk Reduction • Risk in Control – Risk in Treatment 0.36 – 0.22 = 0.14 ; Among 100 patients, there will be 17 less cases of uptransfer with CPAP therapy. 0.31 – 0.20 = 0.11 ; Among 100 patients, there will be 11 less cases of treatment failure with CPAP therapy • Relative risk • Risk in Treatment/Risk in Control 0.22/0.36 = 0.61 ; The risk of uptransfer is 61% less with CPAP therapy 0.20/0.31 = 0.65; The risk of treatment failure is 65% less with CPAP therapy

14. Results • Relative risk reduction • 1 – relative risk 1 – 0.61 = 0.39; The risk of uptransfer is decreased by 39% with CPAP therapy 1 – 0.65 = 0.35; The risk of treatment failure is decreased by 35% with CPAP therapy • Number needed to treat • 1 / absolute risk reduction = 1/ 0.14 = 3.86; We need to treat 4 patients in order to prevent uptransfer with CPAP therapy 1/ 0.11 = 9; We need to treat 9 patients in order to prevent treatment failure with CPAP therapy

15. Applicability • Are the study patients similar to the patients in my practice? YES • Were all clinically relevant outcomes reported? YES • Are the likely treatment benefits worth the harm and costs? YES

16. Authors’ Conclusion CPAP therapy provides significant benefits to infants with respiratory distress in large non-tertiary center with appropriate staff training

17. Reviewers’ Conclusion CPAP therapy among infants with respiratory distress reduced the number of transfer to NICU and treatment failure

18. Thank you 