What Type of CPAP and Why

Brandon Kuehne MBA/RRT-NPS, RPFTErin Wishloff BS/RRT-NPS

Neonatal Respiratory ServicesNationwide Children’s Hospital

Columbus, Ohio2011

Disclosures The Planning Committee and Faculty of

this activity have no disclosed conflicts of interest related to this content.

No commercial support was received for this program

Completion Criteria: In order to receive Continuing Nursing Education (CNE) credit, you must attend 80% of the program.

Agenda

Discuss indications for CPAP / Bi-LevelDiscuss various CPAP / Bi-Level devicesReview ventilators which are approved to

provide NCPAPDescribe available interface devices Finally discuss latest evidence-based

literature of NCPAP

Why use CPAP? Recruitment

Atelectasis Maintenance of FRC

Post extubation Apnea of prematurity RDS

Structural Tracheal malacia

Chest wall stability

To treat an ↑’d WOB

Poor gas exchange

Alternative to intubation

↓ CLD (VON)

↓ VAP

VON Collaborative(As part of an initiative to ↓incidence of BPD)

Looked @ 3 arms activated in D.R.1. Intubate, administer surfactant, remain intubated

2. CPAP, surfactant if indicated, CPAP

3. Intubate, administer surfactant, rapidly extubate to CPAP

– Phase III of collaborative finished for (Small Baby Guidelines) #3 had best patient outcome Primary goal to reduce CLD

– Bubble CPAP chosen method

??? Bubble CPAP ???

Successfully used by Dr. Wung

30+ years Extremely low incidence of BPD/CLD from his

facility

Devices Bubble CPAP

Requirements • Air/O2 proportioner (Blender)• Water column• Modified ventilator circuit (Factory setup

available)

Benefits• Potential for:

Gas exchange due to bubbling• Not easily reproduced

1520 g / CPAP 7cmH2O

A G De Paoli Arch. Dis. Child. 2004

Bubble CPAP Benefits (Cont.)

Relatively inexpensive • Minimal upfront money• Modification of your

current vent circuit

Multiple interface devices available

• Cover a wide range of patients

• Hudson RCI• F&P

Kuehne 2009 11

INCA™ -smallest

Bubble CPAP

Disadvantages

No built in monitors (F&P)• High Pressure / Δ pressure• Disconnect• Apnea

Potential for ↑ WOB Water vs. Tubing depth (25% Acetic Acid)

• Between caregivers

Bubble CPAP Disadvantages

With excessive flow rates a greater than intended peep has been measured at patient.

(M. Wald ET AL., 2010) To create the constant PEEP of 6 with a flow of 4 L/min during

Bubble-CPAP ventilation, the shaft of the underwater seal was adjusted accurately at 6 cm below the waterline.

However, at a flow rate of 10 L/min, the shaft of the underwater seal had to be adjusted at 4 cm below the waterline for creating the correct PEEP of 6.

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F & P Bubble CPAP System

I don’t want to use bubble CPAP, what else can I use?

CF-NCPAP Continuous Flow NCPAP

One of the earliest types of CPAP used• (ET CPAP was earlier)

Prongs connected between the inspiratory and expiratory limb of ventilator

CPAP set by adjusting PEEP and flow

Standard to which many other new CPAP devices are tested against

CF-NCPAP

Advantages Used for past 35+ years = Literature High comfort level with caregivers

Disadvantages Much better options available Proven inferior

CF-NCPAP

Disadvantages

Potential for:• CO2 retention• Respiratory fatigue• ↑ WOB

I don’t want to use CF-NCPAP, what else can I use?

NIPPVNon-Invasive Positive Pressure Ventilation

orNasal Intermittent Positive Pressure Ventilation

Two levels of pressure delivered via ventilator using short bi-nasal prongs or nasopharyngeal prongs.

• Can be achieved with either:• PS/CPAP• Set rate, PIP and PEEP

NIPPV

Potential Benefits Reduction in apnea frequency ↑ CO2 removal Lung recruitment Synchrony may ↓ WOB Use of current facility equipment

NIPPV

Disadvantages Dedicates expensive equipment Potential for:

Dysynchrony due to Trigger: Trigger determined by:

• Leak• Lack of proximal flow measurement (flow probe)

NIPPV Ventilators

FDA 510K NCPAP approved devices:

Viasys AVEA PB-840 Servo I

I don’t want to use NIPPV or I cant’ get NIPPV to work with my babies, what else can I use?

VF-NCPAP

VF-NCPAP

Variable Flow Nasal Continuous Positive Airway Pressure

orFluidic Flip Continuous Positive Airway

Pressure

Comprised of:• An Infant flow generator• An infant flow driver

VF-NCPAP The Generator:

Directs flow toward the patient during inhalation. Then diverts flow away from the patient during exhalation. (The Flip)

VF-NCPAP

Inspiration (Viasys generator) Flow toward patient Pressure constant

How Does It Work?

CPAP pressure is determined by the flow to the generator and prongs or mask

© 2010 CareFusion Corporation or one of its subsidiaries. All rights

reserved.

VF-NCPAP

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VF-NCPAP

Expiration (Viasys generator)

Driver flow + Exhaled patient gas.

Patient

Exha

led

patie

nt g

as

VF-NCPAP

Exhalation:

During exhalation the gas flow is directed away from the patient.

Set pressure is maintained during expiratory phase.

VF-CPAP

Advantages Free standing system Internal monitors Safety dump valve ↓ WOB vs. CF-NCPAP Better delivery of pressure (prescribed) Better synchrony

Disadvantages Up front cost Proprietary circuit

I like the idea of variable flow, but I also like the idea of NIPPV because I like the idea of two pressures. Is there anything else I can use?

What is SiPAP?

SiPAP is a CPAP/Bi-Level device.

That is, it is capable of functioning as a straight forward VF-NCPAP machine. It can also function as a Bi-Level device providing two separate pressures to the patient.

Very similar to APRV or IMV-Pressure control (of sorts, let me explain)

0.000

1.000

2.000

3.000

4.000

5.000

6.000

Seconds

cmH2O

BiPhasic Strategy BiPhasic mode: Cycles between high/low CPAP levels on timed

basis Intermittent increase in CPAP pressure by 2-3 cmH20 for a

duration up to 3.0 seconds to produce a “Sigh breath” Each “Sigh” can augment lung volume by 3-6 ml/kg and unload

work of breathing Enables the infant to breathe spontaneously throughout the

cycle at either pressure.

© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved.

Pandit. Pediatric, 2001; 108 (3):682-685

0.000

1.000

2.000

3.000

4.000

5.000

6.000

Seconds

cmH

2O

Carefusion Corp.time value unknown

SiPAP Currently uses VF-NCPAP interface device Ability to set two pressures

Baseline (CPAP) = Low Pressure Upper Pressure = High Pressure (CPAP to 11cmH2O)

Set I-time during high pressure (0.1 – 3.0 sec) Rate Independent Flow set for low and then above low for high

pressure Alarms

Apnea (Graseby capsule placed on abdomen)Once again, Think Infant Star -StarSync

Pressure (+3/-2 cm H2O) FiO2 (± 5%)

SiPAP

Advantages May stimulate respiratory center

• ↓ # of apneic periods

With both pressures set leads to an ↑ MAP• Improved oxygenation

Provides lung recruitment• as one looks to move, further, or stand-up the

hysteresis curve – what?

0

2

4

6

8

10

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14

0 2 4 6 8 10

CPAP Pressure

Volu

me

Chan

ge (m

l/kg)

Carefusion Corp.

Hysteresis Curve(CPAP should provide a better relationship between

pressure and volume)This is the point from which you want the baby to start breathing; the steeper part of the curve. More Vt for pressure

SiPAP

Advantages (cont.) LCD display

Viasys Healthcare

SiPAP

Disadvantages Potential for hypocarbia Standard learning curve issues – Per the FDA it is a

bi-level cpap device; not a ventilator. (but it sure looks and acts like one)

Not currently synchronized - SNIPPV option not commercially available in U.S.

Airlife nCPAP System (Cardinal Healthcare)

Airlife nCPAP system

Airlife nCPAP system

Airlife nCPAP System

Airlife™ nCPAP System

Potential Benefits Longer anatomically correct - Articulating

silicone Prongs Deeper articulating silicone mask Easily applied fixation device

Potential disadvantages Headgear required Pressure on lip of patients < 1000g Bending/occlusion of prongs

Complications common to all

Septal Breakdown Labor intensive (Sicker patients now on

CPAP)Dry mucosaCPAP Belly Atelectasis due to pressure lossDilated naresDevelopmental delays due to mobility Positioning difficulties

Nationwide Children’s NICU

Patients < 34 weeks and < 2500 grams should be treated with bubble nCPAP Some patients < 34 weeks gestation may not

tolerate bubble nCPAP and may need to be switched to variable flow nCPAP

Patients < 1250 grams should be treated with bubble nCPAP, unless otherwise ordered by the attending neonatologist

Nationwide Children’s NICU

Patients ≥ 34 weeks and ≥ 2500 grams should be treated with variable flow nCPAP Bubble nCPAP is not well tolerated or

applied effectively to older and larger patients mainly due to patients displaying greater mobility.

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Evidence based rationale for using bubble NCPAP for premature baby population

Via head-to-head comparison of bNCPAP vs. infant flow systems (variable flow)

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A Randomized Controlled Trial of Post-extubation Bubble ContinuousPositive Airway Pressure Versus Infant Flow Driver Continuous PositiveAirway Pressure in Preterm Infants with Respiratory Distress Syndrome

SAMIR GUPTA, MD, SUNIL K. SINHA, MD, PHD, WIN TIN, MD, AND STEVEN M. DONN, MD

(J Pediatr 2009;154:645-50)

Gupta cont.

Objective:

To compare the efficacy and safety of bubble continuous positive airway pressure (CPAP) and Infant Flow Driver (IFD) CPAP for the post-extubation management of preterm infants

with respiratory distress syndrome (RDS)

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Gupta cont.

Study design:

A total of 140 preterm infants at 24 to 29 weeks’ gestation or with a birth weight of 600 to 1500 g who were ventilated at birth for RDS were randomized to receive either IFD CPAP (a variable-flow device) or bubble CPAP (a continuous-flow device). A standardized protocol was used for extubation and CPAP. No crossover was allowed. The primary outcome was successful extubation maintained for at least 72 hours.

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Gupta cont.

Results:

Seventy-one infants were randomized to bubble CPAP, and 69 were randomized to IFD CPAP. Mean gestational age and birth weight were similar in the 2 groups, as were the proportions of infants who achieved successful extubation for 72 hours and for 7 days.

The median duration of CPAP support was 50% shorter in the infants on bubble CPAP. Moreover, in the subsetof infants who were ventilated for less than 14 days, the infants on bubble CPAP had a significantly lower extubation failure rate.

There was no difference in the incidence of chronic lung disease or other complications between the 2 study groups

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Conclusions:

Bubble CPAP is as effective as IFD CPAP in the post-extubation management of infants with RDS; however, in infants ventilated for < 14 days, bubble CPAP is associated with a significantly higher rate of successful extubation.

Bubble CPAP also is associated with a significantly reduced duration of CPAP support.

NCPAP vs. Bi-level NCPAPNasal continuous positive airway pressure (CPAP) versus bi-level nasal CPAP in preterm

babies with respiratory distress syndrome: a randomized control trial

Gianluca Lista, Francesca Castoldi, Paola Fontana, Irene Daniele, Francesco Cavigioli, Samantha Rossi,

Diego Mancuso, Roberta Reali(Arch Dis Child Fetal Neonatal ED 2010;95:F85-F89)

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Lista cont.

Objective:

To compare the clinical course and outcome of RDS infants managed with bi-level nasal cpap versus nasal cpap.

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Lista cont.

Study Design:

A total of 40 RDS infants with a GA 28-34 weeks were randomized to either a NCPAP of 6cm H20 or a bi-level NCPAP of pressure low 4.5 and pressure high 8 cm H20.

Infant Flow Driver used in both arms.

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NCPAP vs. Bi-level Mode

Outcome Infant Flow Bi-level

Days of respiratory support 6.2 days 3.8 daysDays on oxygen 13.8 days 6.5 daysGestational age at discharge 36.7 wks 35.6 wks

Conclusion:“Bi-level nCPAP was associated with better respiratory outcomes versus nCPAP, and allowed earlier discharge.”

Lista G, et al. Arch Dis Child Fetal Neonatal Ed. 2010 Mar;95

© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved.60

Results:

NCPAP vs. Bi-level NCPAP

Nasal Bilevel vs. Continuous Positive Airway Pressure in Preterm Infants

Claudio Migliori, Mario Motta, Agnese Angeli, and Gaetano Chirico (Pediatric Pulmonology, 2005 40:426-430)

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© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved. 62

Study Design:

20 infants 24-31 weeks (mean 29.6 wks)

Infants evaluated during a 4 hour period; alternating nCPAP and biphasic ventilation phases lasting 1 hour each

Settings

NCPAP• 4-6 cmH2O

Biphasic• Rate of 30• Time high 0.5 seconds• Pressure high 4 cmH2O above NCPAP pressure

Migliori et al, Pediatric Pulmonology.2005: 40:426 – 430

Migliori cont.

Results:

All patients completed the study without need for reintubation. For the two Biphasic periods, a significant increase in Pa02 and decrease in PaC02 was noted compared with the NCPAP periods.

No cardiovascular differences were noted during any of the phases.

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Migliori cont.

NCPAP vs. Bi-level NCPAP

Conclusion:

Biphasic mode associated with…

Significant increase in peripheral oxygen saturation and transcutaneous PaO2

Significant reduction in transcutaneous PaCO2

Reduction in respiratory rate

Improvement in heart rate and blood pressure

© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved. 64

Nasal intermittent postivie pressure ventilation in the newborn: a review of literature and evidence-based guidelines.

V Bhandari (2010)

Literature review of SNIPPV and its us as1. Primary Mode- referring to its use soon after birth2. Secondary Mode- referring to its use after a longer period from > 2hr to days or

weeks.

Studies using SNIPPV as primary mode have shown: Decrease in duration of oxygen use in SNIPPV vs. CV. Decrease incidence in BPD when comparing SNIPPV vs. NCPAP.

Studies using SNIPPV as secondary mode have shown: SNIPPV to be significantly better then NCPAP in preventing extubation failure. SNIPPV infants to have decreased need for supplemental oxygen and

decreased BPD compared to NCPAP infants.

Kuehne 2009 65

Questions and answers