Old CPAP is back with a bang

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Old CPAP is back with a bang

• Dr Rajesh Kumar
• MD (Paed), DM (Neo)

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CPAP a lost art

• Deemed ineffective in VLBW
• ? It increases the risks of IVH due to raised
  CO2.
• Progress in ventilator technology making
  intubation and ventilation more effective and
  safer

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Comeback of CPAP

• Surfactant making management of RDS simpler.
• Low incidence of chronic lung disease associated
  with use of CPAP.
• Concept of prophylactic CPAP and minimal handling
  in the care of VLBW

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Effective
CPAP
Simple
Low cost technology
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• CPAP alone for RDS
• CPAP with surfactant for RDS
• Early CPAP for RDS
• CPAP as prophylactic therapy
• CPAP in post extubation period
• CPAP in apnea of prematurity
• CPAP in other neonatal lung diseases (Pneumonia,
  MAS)

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Efficacy of CPAP for RDS
Continuous distending pressure for respiratory
distress syndrome in preterm infants
Ho JJ, Subramaniam P, Henderson-Smart DJ, Davis
PG Cochrane Review, Last update June 2000

• 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).

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CPAP in RDS How does it work ?

• Diminishing atelectasis
• Improving Functional residual capacity
• Correcting ventilation-perfusion abnormalities
• Decreasing pulmonary edema
• Reducing intrapulmonary shunting

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CPAP In RDS guidelines
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CPAP Indications

• Premature baby with
• FiO2 above 0.3 with clinical distress
• FiO2 above 0.4
• Significant retractions

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Surfactant and CPAP
Surfactant Therapy and Nasal Continuous Positive
Airway Pressure for Newborns with Respiratory
Distress Syndrome
N Engl J Med 1994 3311051-1055, 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.
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Surfactant with CPAP Technique

• INSURE Technique
• Intubate
• Surfactant
• Extubate

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Surfactant use in level II

• Criteria for surfactant use
• Clinical and/or radiological evidence of RDS.
• Gestational age ³ 32/40.
• Age less than 72 hours.
• Increasing requirements, e.g.. FiO2 gt 50, pH lt
  7.25, PaO2 lt 50, PaCO2 gt 50

• Unlikely candidates
• Birth asphyxia.
• Pneumonia.
• Pneumothorax.
• Severe malformations.
• Prolonged ROM gt 5 days.
• Meconium Aspiration Syndrome

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The milder the RDS, the sooner the infant will
find himself in 100 oxygen and maximal
ventilatory support.
Spitzer A Spizers law of neonatology. Cin
Pediatr 20 733, 1981.
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Early CPAP for RDS
Early versus delayed initiation of continuous
distending pressure for respiratory distress
syndrome in preterm infants
Ho 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).

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Prophylactic CPAP
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Prophylactic CPAP

• Avoids the serious side effects related to
  intubation and ventilation
• Can prevent or decrease the severity of RDS
• Decreased incidence of RDS

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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

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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 56214, 1975

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CPAP administration

• Nasal interfaces
• Technique for pressure generation

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Nasal interfaces

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Nasal interfaces
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Nasopharyngeal ET tube
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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

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Bubble CPAP system
Fisher and paykel Infant Bubble CPAP System
Indigenous Infant Bubble CPAP System
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Levels of CPAP
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Failure of CPAP

• PaO2 lt50 mm Hg in 100 oxygen at pressure 10-12
  cm H2O
• If nasal CPAP fails, ET CPAP can be tried
• IPPV if PaO2 is lt50 mm Hg or pH lt7.25

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Effective
CPAP
Simple
Low cost technology
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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

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• Thank You

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