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Minimally-invasive ventilation WorkshopContinuous positive airway pressure ventilation

Amer Ammari, MB, BS

John Kawas, RRTRiyadh Military Hospital

Introduction Progress in neonatal intensive care is closely linked to improvements in the management of respiratory failure in small infants. Current modalities of ventilatory assistance range from more benign continuous positive airway pressure (CPAP) to various modes of mechanical ventilation (including high frequency ventilation).polin and Sahni, Seminars in Neonatology, 2002

Introduction

The advent of less invasive methods of delivering CPAP has permitted earlier treatment of infants with RDS and avoided the need for mechanical ventilation.

polin and Sahni, Seminars in Neonatology, 2002

Introduction The early initiation of nasal CPAP in combination with a tolerance to elevated PCO2 levels has reduced the incidence of BPD in many centers.Kamper et al , 2004 (the ETFOL study)

BPD is a complex pulmonary disease, characterized by inflammation and abnormal lung repair.Reese et al 2001, polin and Sahni 2002

While prenatal, natal and postnatal events are important in its pathogenesis, Ventilation is thought to be a major contributing factor.Jobe and Ikegami 2001

Effects of CPAP in the infant with respiratory distress1. Reduces upper airway occlusion by decreasing upper airway resistance and increasing the pharyngeal cross sectional area.2. Reduces right to left shunting. 3. Reduces obstructive apneas. 4. Increases the FRC. 5. Reduces inspiratory resistance by dilating the airways. This permits a larger tidal volume for a given pressure, so reducing the work of breathing. 6. Reduces the compliance of very compliant lungs and, in these lungs, reduces the tidal volume and minute volume.

7. Increases the compliance and tidal volume of stiff lungs with a low FRC by stabilizing the chest wall and counteracting the paradoxical movements. 8. Regularizes and slows the respiratory rate.

9. Reduces the incidence of apnea.10. Increases the mean airway pressure and improves ventilation perfusion mismatch. 11. Conserves surfactant on the alveolar surface. 12. Diminishes alveolar edema. 13. The increased pressure helps overcome the inspiratory resistance of an endotracheal tube. 14 Nasal CPAP after extubation reduces the proportion of babies requiring re-ventilation. 15 Oxygenation is related to the surface area, and carbon dioxide elimination is related to the minute volume. Normalizing lung volume improves oxygenation and carbon dioxide elimination.

Indications for CPAP1. Spontaneously breathing babies with respiratory distress at birth.

2. Increased work of breathing indicated by: recession, grunting, nasal flaring, increased oxygen requirements or increased respiratory rate.3. Poorly expanded or infiltrated lung fields on chest x-ray. 4. Atelectasis. 5. Pulmonary edema. 6. Pulmonary hemorrhage. 7. Apnoea of prematurity. 8. Recent extubation. 9. Tracheomalacia or other abnormalities of the airways, predisposing to airway collapse. 10.Phrenic nerve palsy.

Contraindications to CPAP

1. The need for ventilation because of ventilatory failure inability to maintain oxygenation and the arterial PaCO2 7.25. 2. Upper airway abnormalities (cleft palate, choanal atresia). 3. Tracheo-oesophageal fistula. 4. Diaphragmatic hernia. 3. Severe cardiovascular instability.

Bubble nasal continuous positive airway pressure system

CPAP delivery systemsThe CPAP delivery system consists of three components: the circuit for continuous flow of inspired gases, the interface connecting the CPAP circuit to the infants airway, and a method of creating positive pressure in the CPAP circuit.

The amount of CPAP may be varied by a change in the amount of gas flow into the system or by the amount of obstruction to the outflow (5 cm of fluid level in the case of bubble nasal CPAP).

Many techniques are available to deliver CPAP

Nasal cannulae Face masks Nasal prongs Nasopharyngeal tubes

Head box with nasal seal& Endotracheal tubes.

Types of prongs Argyle Hudson Inca Fisher & Paykel EME Others

CPAP Pressure Generators

Ventilator CPAP

Flow Driver CPAP Bubble Bottle CPAP

Others

Bubble nasal CPAP

Why Bubble Bottle CPAP? Cheap Readily available

Effective Oscillation/vibration may contribute to effect (15-30 HZ)**Nekvasil et al, 1992. Pillow and Travadi, 2005. Lee et al, 1998

Nasal Prong Interface

What to use?

De Paoli et al, Arch Dis Child Fetal Neonatal Ed 2002

The higher the resistance, the lesser the pressure transmitted through the prongs to the nose of the baby. Hudson prongs and the infant flow driver have the least resistance to flow.

Advantages and disadvantages of Nasal Prongs CPAPAdvantages Easy to apply; flexible and enable change in infants position; low airway resistance, easily controlled, stabilized and eliminates need for intubation. Disadvantages Nasal septal erosion or necrosis; nasal obstruction from secretions or improper position of CPAP prongs; abdominal distension from swallowing air.

Polin and Sahni, Seminars in neonatology 2002

Building the Bubble Bottle NCPAP Delivery System Initiating Bubble Bottle NCPAP Delivery System Care of the Infant on NCPAP

Building the bubble CPAP apparatus

Bubble CPAP Delivery System

Preparation (1)Gather the following equipment Oxygen/Air flow sources Oxygen blender with flow meter Oxygen tubing to lead from the blender

to the humidifier Oxygen analyzer (optional) Humidifier filled to the appropriate level with sterile water Corrugated circuit tubing with humidifier connections Humidifier temperature probe Nasal prong CPAP set

Preparation(2)Gather the following equipment 500-1000 cc bottle of 0.25% acetic acid or sterile water 10cc syringe / 3 cc syringe Luer plug/prn adapter/Pressure tubing 4 small safety pins 2 small rubber bands Tegaderm Gauze swabs Paper measuring tape Tape- adhesive

HUDSON NASAL PRONG SIZEsize 0 for < 700 g size 1 for 700-1000 g size 2 for 1000-2000 g size 3 for 2000-3000 g size 4 for 3000-4000 g size 5 for > 4000 gFor infants at the high end of any of the weight ranges, consider using the larger prongs appropriate for the next higher weight range

Nasal CPAPSet up (1)1. Attach the oxygentubing to the flow meter and blender, and connect the tubing to the humidifier 2. Set the flow meter to deliver 5 10 liters per minute

Flow 5 10 lpm

Nasal CPAPSet up (2)3. Turn on thehumidifier, set the temp at 36.8 37.3 0 C, and chamber temp.(-2) 4. Attach one corrugated tube to the humidifier

Nasal CPAPSet up (3)5. Connect thehumidifier tube temperature probe to the corrugated tubing going to the baby 6. Choose appropriate size nasal prongs and attach them to the corrugated tubing

Nasal CPAPSet up (4 )7. Attach corrugatedcircuit tube to the other side of prongs. Fix the Luer plug in place over the opening in the elbow of the prongs

Nasal CPAPSet up (5)7. Secure measuringtape to the outlet bottle containing 0.25% acetic acid or sterile water, with the 7 cm mark at the base 8. Empty fluid to the 0 mark

Nasal CPAPSet up (6)9. Place the end of thecorrugated tube into the water to a depth of 5 cm to create 5 cm of CPAP 10.Fix the tubing in place by sliding the 10cc/3cc syringe (plunger removed) into the neck of the bottle

Care of the Infant on NCPAP

Success with NCPAPNCPAP is successful when meticulous attention is paid to both the infant and to the NCPAP Delivery System. This involves vigilance in: Monitoring the infants condition Maintaining an optimal airway Maintaining a patent CPAP delivery circuit Prevention of complications which may arise from NCPAP

Monitoring the Infants Condition Once NCPAP is applied, theinfants condition must be monitored frequently Observe the infant q 1 hr over the first 4 hours of life, and then q 3-4 hr thereafter while on NCPAP. Any infant experiencing significant respiratory distress while on NCPAP requires closer observation for change in condition.

Monitoring the Infants ConditionRecommended monitoring: Respiratory status (RR, work of breathing) Pre ductal oxygen saturation Cardiovascular status (HR, BP, perfusion) GI status (abdominal distention, bowel sounds) Neurological state (tone, activity, responsiveness) Thermoregulation (temp)

Maintaining Optimal Airway Care: Suctioning Suction the mouth,nose and pharynx q 3 hr For symptomatic infants more frequent suctioning may be needed

Maintaining Optimal Airway Care: Suctioning Moisten the nares withnormal saline or sterile water to lubricate the catheter and loosen dry secretions. It may be necessary to pass the suction catheter more than once to ensure adequate airway clearance.

Maintaining Optimal Airway Care: Humidification Maintain adequatehumidification of the circuit to prevent drying of secretions. Adjust settings to maintain gas humidification at or close to 100%. Set the humidifier temperature to 36.837.3o C.

Prevent complications

Complications associated with bubble nasal CPAP Pneumothorax / PIE - more in the acute phase - not a contraindication for continuing CPAP Nasal obstruction -Remove secretions and check for proper positioning of the prongs Nasal septal erosion or necrosis -Keep prongs away from the septum Gastric distension Intermittent or continuous aspiration of the stomach Feeding intolerance

Preventing Complications: Nasal Septal Injury Septal injury is preventable Damage to the septum ariseswhen poorly fitted or mobile prongs cause pressure and/or friction. Excess moisture from gels, lubricants or duoderm-like products un