Nasal Continuous Positive Airway Pressure versus High-flow Nasal Cannula in Preterm Respiratory Distress Syndrome: Escalation Rates, Respiratory Trajectory, and Predictors of Treatment Failure: A Prospective Comparative Study

Abstract

A BSTRACT Noninvasive respiratory support is central to preterm respiratory distress syndrome (RDS) management, yet evidence comparing nasal continuous positive airway pressure (nCPAP) and high-flow nasal cannula (HFNC) as primary support from resource-limited settings remains scarce. This study compared outcomes of nCPAP and HFNC as initial respiratory support in preterm neonates with RDS at a government tertiary neonatal intensive care unit in India. This prospective comparative study enrolled 376 preterm neonates (gestational age 28–36 weeks) with RDS between August 2023 and February 2025. The primary outcome was escalation of respiratory support. The secondary outcomes included mortality, fraction of inspired oxygen at initiation of nCPAP (FiO 2 ) trajectory, Downes score, complications, and discharge outcomes. Binary logistic regression identified predictors of escalation. Escalation occurred in 30 (17.0%) nCPAP and 80 (40.0%) HFNC recipients, an absolute risk difference of 23.0% ( P < 0.001). All 15 (8.5%) deaths occurred in the nCPAP group among neonates escalated to mechanical ventilation; no deaths occurred in the HFNC group ( P < 0.001). nCPAP recipients required lower FiO 2 at all postinitiation time points (6 h–48 h; all P < 0.01) and achieved room air earlier (103.09 vs. 115.04 h, P < 0.001). Nasal trauma was more frequent with nCPAP (34.7% vs. 17.5%, P < 0.001) and recurrent apnea with HFNC (19.5% vs. 8.0%, P = 0.002). In multivariate analysis, HFNC use (adjusted odds ratio [aOR]: 3.29, 95% confidence interval [CI]: 1.89–5.70) and maternal chorioamnionitis (aOR: 4.09, 95% CI: 2.38–7.01) were the strongest independent predictors of escalation. nCPAP showed superior oxygenation and lower escalation rates than HFNC, supporting its use as the preferred initial modality for preterm RDS in resource-limited settings, while identifying chorioamnionitis-exposed neonates as a high-risk subgroup warranting monitoring.