Occlusive versus non-occlusive CPAP interfaces in neonatal respiratory care: a comparative review of efficacy and safety.

BACKGROUND: Continuous positive airway pressure (CPAP) is first-line therapy for respiratory distress in preterm infants, but optimal interface selection remains controversial. Occlusive interfaces (nasal prongs and masks with tight seals) provide accurate pressure delivery but can cause significant nasal trauma, while non-occlusive interfaces (loosely fitting nasal cannulae) reduce trauma but may compromise therapeutic efficacy. OBJECTIVE: To synthesise current evidence comparing occlusive with non-occlusive CPAP interfaces regarding pressure delivery accuracy, clinical efficacy, safety outcomes and practical implementation in neonatal intensive care. METHODS: Comprehensive review of randomised controlled trials, systematic reviews, bench studies and observational studies comparing CPAP interface types in preterm neonates. Evidence quality assessed using the Grading of Recommendations Assessment, Development and Evaluation criteria where applicable. RESULTS: Occlusive interfaces deliver pressure within 0.5-1.0 cmH2O of set values and demonstrate superior efficacy in landmark trials (COIN, SUPPORT), particularly in extremely preterm infants (<28 weeks' gestation). However, nasal trauma rates reach 20-60%. Non-occlusive systems reduce trauma dramatically (0-5.4% injury rates) but consistently underdeliver pressure. Non-occlusive systems have failed to meet non-inferiority criteria in recent trials, with CPAP failure rates of 19.7% versus 17.3% for occlusive systems. This increased to failure rates >50% in extremely preterm infants. CONCLUSIONS: Current evidence supports occlusive CPAP as first-line therapy for moderate-to-severe respiratory distress in preterm neonates, particularly those of <32 weeks' gestation. Non-occlusive interfaces may be appropriate for stable infants, weaning support or apnoea of prematurity management. Adequately powered randomised trials stratified by gestational age and respiratory severity are urgently needed to define optimal interface selection strategies.