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