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Foto Ann-Sofi Ingman
Continuous Positive Airway Pressure
(CPAP) and Work of Breathing
Baldvin Joacutensson MD PhD
Karolinska Institutet and University Hospital Stockholm Sweden
Static pressure-volume curves of lung (PL) Chest wall (PW)
and total respiratory system Arrows indicate static forces
Chest wall recoil is outward and lung recoil is inward
Pulmonary physiology
Lung volume is related to transpulmonary pressure
Transpulmonary pressure = alveolar pressure - pleural pressure
Compliance is mL)cm H2O
Work of breathing = integral of pressure applied and resulting volume change (W = P dVminkg)
Preterm breathing strategy is directed
toward control of absolute lung volume
High respiratory rate to achieve auto end-expiratory-pressure
Active expiration against laryngeal narrowing
Tonic activity of diaphragm and intercostal muscles
Respiratory fatique in newborns
Diaphragmatic muscle fatique demonstarted in newborns on
CPAP and mechanical ventilation (Miller et al J Appl Physiol 1979)
Controversy exists about the relative importance of central or
peripheral mechanisms that contribute to fatique (Roussos and
Zakyntos Intensive Care Med 1996)
Hypoxia accentuates fatique during loaded breathing in an
animal model (Radell P et al J Appl Physiol 2000)
9 juni 2012 Baldvin Joacutensson 5
Work of Breathing
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Static pressure-volume curves of lung (PL) Chest wall (PW)
and total respiratory system Arrows indicate static forces
Chest wall recoil is outward and lung recoil is inward
Pulmonary physiology
Lung volume is related to transpulmonary pressure
Transpulmonary pressure = alveolar pressure - pleural pressure
Compliance is mL)cm H2O
Work of breathing = integral of pressure applied and resulting volume change (W = P dVminkg)
Preterm breathing strategy is directed
toward control of absolute lung volume
High respiratory rate to achieve auto end-expiratory-pressure
Active expiration against laryngeal narrowing
Tonic activity of diaphragm and intercostal muscles
Respiratory fatique in newborns
Diaphragmatic muscle fatique demonstarted in newborns on
CPAP and mechanical ventilation (Miller et al J Appl Physiol 1979)
Controversy exists about the relative importance of central or
peripheral mechanisms that contribute to fatique (Roussos and
Zakyntos Intensive Care Med 1996)
Hypoxia accentuates fatique during loaded breathing in an
animal model (Radell P et al J Appl Physiol 2000)
9 juni 2012 Baldvin Joacutensson 5
Work of Breathing
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Pulmonary physiology
Lung volume is related to transpulmonary pressure
Transpulmonary pressure = alveolar pressure - pleural pressure
Compliance is mL)cm H2O
Work of breathing = integral of pressure applied and resulting volume change (W = P dVminkg)
Preterm breathing strategy is directed
toward control of absolute lung volume
High respiratory rate to achieve auto end-expiratory-pressure
Active expiration against laryngeal narrowing
Tonic activity of diaphragm and intercostal muscles
Respiratory fatique in newborns
Diaphragmatic muscle fatique demonstarted in newborns on
CPAP and mechanical ventilation (Miller et al J Appl Physiol 1979)
Controversy exists about the relative importance of central or
peripheral mechanisms that contribute to fatique (Roussos and
Zakyntos Intensive Care Med 1996)
Hypoxia accentuates fatique during loaded breathing in an
animal model (Radell P et al J Appl Physiol 2000)
9 juni 2012 Baldvin Joacutensson 5
Work of Breathing
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Preterm breathing strategy is directed
toward control of absolute lung volume
High respiratory rate to achieve auto end-expiratory-pressure
Active expiration against laryngeal narrowing
Tonic activity of diaphragm and intercostal muscles
Respiratory fatique in newborns
Diaphragmatic muscle fatique demonstarted in newborns on
CPAP and mechanical ventilation (Miller et al J Appl Physiol 1979)
Controversy exists about the relative importance of central or
peripheral mechanisms that contribute to fatique (Roussos and
Zakyntos Intensive Care Med 1996)
Hypoxia accentuates fatique during loaded breathing in an
animal model (Radell P et al J Appl Physiol 2000)
9 juni 2012 Baldvin Joacutensson 5
Work of Breathing
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Respiratory fatique in newborns
Diaphragmatic muscle fatique demonstarted in newborns on
CPAP and mechanical ventilation (Miller et al J Appl Physiol 1979)
Controversy exists about the relative importance of central or
peripheral mechanisms that contribute to fatique (Roussos and
Zakyntos Intensive Care Med 1996)
Hypoxia accentuates fatique during loaded breathing in an
animal model (Radell P et al J Appl Physiol 2000)
9 juni 2012 Baldvin Joacutensson 5
Work of Breathing
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Work of Breathing
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
How can we help the infant
9 juni 2012 Baldvin Joacutensson 8
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
The Perfect CPAP
Should keep airway pressure as constant as possible to reduce
WOB
any deviations in pressure add to WOB done by the patient
FRC should rise proportionately to the increase in level of CPAP
This requirement means that the device must have highly variable
flow characteristics to be able to
accelerate flow on inspiration without time lag
on expiration pressures should not overshoot thus maintaining a low
WOB
Differences in failure rates between studies can possibly be
attributable to the performance of the devices used (dePaoli 2003)
9 juni 2012 Baldvin Joacutensson 9
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
5 week old male 840g spontaneous breaths with
airway pressure measured in nasopharynx
Pressure variations during spontaneous
breathingno CPAP applied
Argyle nasal prong without CPAP attached
Argyle nasal prong with 4cm CPAP
Jet flow CPAP 4cm
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Total work of breathing (Campbell diagram)
Increase by
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
9 juni 2012 Baldvin Jonsson 13
CPAP applied via ET-tube or head box (Gregory et al N EJM 19712841333-40)
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
New device
Old device
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Physiologic tests for WOB
CLINCAL studies comparing different devices
9 juni 2012 Baldvin Joacutensson 16
Pandit et al 2001 Ventilator vs Variable Flow
Courtney et al 2003 Variable Flow vs Variable Flow
Liptsen et al 2005 Bubble vs Variable Flow
Courtney et al 2011 Bubble vs Ventilator
VF gt Ventilator
Bubble ge ventilator when intraprong P is same
VF 1 gt VF 2
VF gt Bubble
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Clinical studies using CPAP system
specification
Early CPAP DR feasability (Pediatrics 2004)
rdquoNeoPuff T-piece for CPAP
Coin Study (NEJM 2009)
System for CPAP use not specified
SUPPORT (NEJM 2010)
rdquoCPAP administered via T-piece systemrdquo
9 juni 2012 Baldvin Joacutensson 17
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Compare existing systems used for
NCPAP care using simulated neonatal
breathing
Devices 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
9 juni 2012 Baldvin Joacutensson 19
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Mechanical lung model (ASL 5000)
NCPAP system
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Mechanical lung model (ASL 5000)
Imposed WOB = Expiratory Imposed WOB + Inspiratory Imposed WOB
NeoPuff 4 cm H2O Breath profile from 35 kg infant
Inspiratory
WOB
(Area)
Expiratory
WOB
(Area)
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Breath profiles used
9 juni 2012 Baldvin Joacutensson 22
Recorded flow from a healthy male
newborn with a body weight of 34 kg
Sample from Moa et al
Recorded flow from a healthy
preterm (26 weeks) female at 28
weeks corrected age with a weight of
13 kg on recording
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
9 juni 2012 Baldvin Joacutensson 23
Drevhammar T Nilsson K Zetterstroumlm H Jonsson BComparison of seven infant continuous
positive airway pressure systems using simulated neonatal breathing Pediatr Crit Care Med
2012 13e113ndash e119
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Effect of leak
9 juni 2012 Baldvin Joacutensson 24
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
System summary
9 juni 2012 Baldvin Joacutensson 25
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
Conclusions
Large variations in pressure stability and iWOB exist between
the different devices
Clinical significance if any needs to be assessed
9 juni 2012 Baldvin Joacutensson 26
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
9 juni 2012 Baldvin Joacutensson 27
Nikischin et al Pediatr Crit Care Med 2011
![Airway & Breathing Management [Compatibility Mode]](https://img.pdfslide.us/doc/110x75/563db829550346aa9a911da5/airway-breathing-management-compatibility-mode.jpg)
