old cpap is back with a bang dr rajesh kumar md (paed), dm (neo)

Old CPAP is back with a

bangDr Rajesh KumarMD (Paed), DM (Neo)

Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure.

Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK

N Engl J Med 1971 Jun 17;284(24):1333-40

CPAP a lost art

1. Deemed ineffective in VLBW

2. ? It increases the risks of IVH due to raised

CO2.

3. Progress in ventilator technology making

intubation and ventilation more effective and

safer

Comeback of CPAP

1. Surfactant making management of RDS

simpler.

2. Low incidence of chronic lung disease

associated with use of CPAP.

3. Concept of prophylactic CPAP and minimal

handling in the care of VLBW

Effective

SimpleLow cost

technologyCPAP

1. CPAP alone for RDS

2. CPAP with surfactant for RDS

3. Early CPAP for RDS

4. CPAP as prophylactic therapy

5. CPAP in post extubation period

6. CPAP in apnea of prematurity

7. CPAP in other neonatal lung diseases (Pneumonia, MAS)

• Overall mortality [RR 0.52 (0.32, 0.87), NNT 7 (4, 25)]

• Mortality in birth weights above 1500 g [RR 0.24 (0.07, 0.84), NNT 4 (2, 13)].

Continuous distending pressure for respiratory distress syndrome in preterm infants

Ho JJ, Subramaniam P, Henderson-Smart DJ, Davis PGCochrane Review, Last update June 2000

Efficacy of CPAP for RDS

CPAP in RDS: How does it work ?

• Diminishing atelectasis

• Improving Functional residual capacity

• Correcting ventilation-perfusion abnormalities

• Decreasing pulmonary edema

• Reducing intrapulmonary shunting

CPAP In RDS: guidelines

CPAP Indications

Premature baby with

• FiO2 above 0.3 with clinical distress

• FiO2 above 0.4

• Significant retractions

Surfactant and CPAPSurfactant Therapy and Nasal Continuous Positive Airway Pressure for Newborns with Respiratory Distress Syndrome N Engl J Med 1994; 331:1051-1055, Oct 20, 1994 Henrik Verder, Bengt Robertson, Gorm Greisen, Finn Ebbesen, Per Albertsen, Kaare Lundstrom, Thorkild Jacobsen,

for The Danish-Swedish Multicenter Study Group Conclusions In babies with moderate-to-severe respiratory distress

syndrome treated with nasal continuous positive airway pressure, a single dose of surfactant reduced the need for subsequent mechanical

ventilation.

Surfactant with CPAP: Technique

INSURE Technique

• Intubate

• Surfactant

• Extubate

Surfactant use in level II

Criteria for surfactant use

• Clinical and/or radiological evidence of RDS.

• Gestational age 32/40.

• Age less than 72 hours.

• Increasing requirements, e.g.. FiO2 > 50%, pH < 7.25, PaO2 < 50, PaCO2 > 50

Unlikely candidates

• Birth asphyxia.

• Pneumonia.

• Pneumothorax.

• Severe malformations.

• Prolonged ROM > 5 days.

• Meconium Aspiration Syndrome

The milder the RDS, the sooner the infant

will find himself in 100% oxygen and

maximal ventilatory support.

Spitzer A: Spizer’s law of neonatology.

Cin Pediatr 20: 733, 1981.

Early CPAP for RDSEarly versus delayed initiation of continuous distending pressure

for respiratory distress syndrome in preterm infantsHo JJ, Henderson-Smart DJ, Davis PG Cochrane Review, Last update Feb 2002

• Reduction in IPPV use in the early CPAP [RR 0.55 (0.32, 0.96), NNT 6 (4, 33)].

• Trend for decreased mortality [RR 0.68 (0.34, 1.38)].

Prophylactic CPAP

Acta Paediatr 1993 Nov;82(11):934-8"Minitouch" treatment of very low-birth-weight infants.

Jacobsen T, Gronvall J, Petersen S, Andersen GE.

Prophylactic CPAP

• Avoids the serious side effects related to intubation and ventilation

• Can prevent or decrease the severity of RDS

• Decreased incidence of RDS

CPAP after extubation

• Prophylactic CPAP is effective in preventing failure of extubation in VLBW babies

• Decreased apnea, respiratory acidosis

Davis P, Henderson SS. J Pediatric child health. 1999; 35(4): 367-71

MAS and CPAP

• Low and medium CPAP is helpful in increasing the oxygenation

• PEEP does not increase the incidence of pneumothorax

Fox WW, Berman LS, Downes JJ, et al. The therapeutic application of end expiratory pressure in MAS. Pediatrics 56:214, 1975

CPAP administration

• Nasal interfaces

• Technique for pressure generation

Nasal interfaces

•

Nasal interfaces

Nasopharyngeal ET tube

TECHNIQUES FOR PRESSURE GENERATION

• Expiratory flow valve (e.g. ventilator)

• Underwater tube 'bubble' CPAP (underwater expiratory resistance)

• Benveniste device (pressure generation at nasal level: gas jet device connected to nasal prong/s)

• Infant Flow Driver (IFD) system (pressure generation in Infant Flow 'Generator' at nasal level

Bubble CPAP system

Fisher and paykel Infant Bubble CPAP System

Indigenous Infant Bubble CPAP System

Levels of CPAP

Failure of CPAP

• PaO2 <50 mm Hg in 100% oxygen at pressure 10-12 cm H2O

• If nasal CPAP fails, ET CPAP can be tried

• IPPV if PaO2 is <50 mm Hg or pH <7.25

Effective

SimpleLow cost

technologyCPAP

Summary

• CPAP is simple and effective low cost technology

• Apply CPAP early in RDS

• Whenever in doubt use CPAP

• Need for increasing the awareness for the use of CPAP and Surfactant