Background Many very preterm infants managed on early nasal continuous positive airway pressure (nCPAP) subsequently require intubation and ventilation and may suffer the consequences of delayed surfactant administration. We investigated risk factors for early nCPAP failure in European regions with diverse approaches to respiratory support.

Methods The EPICE cohort included all births between 22+0 and 31+6 weeks of gestation in 19 European regions in 2011–2012. nCPAP failure was defined as mechanical ventilation in the first 72 h. Independent variables were gestational age, sex, multiple pregnancy, prenatal corticosteroids, pregnancy complications, small for gestational age (SGA), caesarean delivery, 5 min Apgar and region of birth. We classified regions into low (<35%), medium (35–55%) and high (≥55%) early nCPAP use. Time to CPAP failure was modelled using Cox models.

Results Of 7566 infants admitted to neonatal care, 3360 (44%) received early CPAP with a range from 21% to 81% across regions; 22% of infants failed CPAP, with a regional range of 11% to 61%. Failure rates were 47% at <26 weeks, 29% at 26–29 weeks and 16% at 30–31 weeks. In adjusted models, low gestational age, male sex, SGA, Apgar <7, no prenatal steroids, and maternal hypertension were associated with failure. Regions with low and intermediary nCPAP use had higher failure rates (adjusted hazard ratio (aHR): 1.3 95% CI: 1.0–1.6 and aHR: 1.4 95% CI: 1.2–1.7, respectively) than high-use regions.

Conclusions Perinatal factors identify infants likely to experience nCPAP failure. However, experience and training may also play an important role in effective nCPAP.