A History of CPAP for Infants

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A History of CPAP for Infants

• Alan H. Jobe, MD, PhDCincinnati Childrens
  Hospital
• University of Cincinnati
• Cincinnati, Ohio

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Neonatal Bioethics The Moral Challenges of
medical Intervention

• The era of innovation and individualism
  1965-1982
• Mechanical Ventilation
• CPAP
• Total Parental Nutrition
• Regionalization
• Era of exposed ignorance 1982-1992
• The End of Medical Progress after 1992

Lantos and Meadow, Neonatal Bioethics, 2006
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First Reference to CPAP in Pub MedRevival of
an Old Battle Intermittent vs. Continuous
Positive-Pressure Breathing

• Continuous Pressure Breathing effective in WWII
  for high altitude pilots, but increases work of
  breathing and decreases cardiac output.
• Advantages of CPB over IPB
• Improved oxygenation at lower FiO2
• Disadvantages of CPP over IPB
• Need to measure CO
• Indicated only in cases where alveolar pressure
  is not transmitted to the intra plural spaces
• Alveolar rupture and Pneumothorax
• Editorial in NEJM December, 1970, Claude Lenfant

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(No Transcript)
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Responses of Switching 8 Patients from PEEP13
cmH2O to No PEEP
Kunar, et al., NEJM, 1970
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Status of Hyaline Membrane Disease Late 1960s

• HMD was leading cause of death for preterms
  (27-43 survival with assisted ventilation
  worldwide) 1968-1971
• Ventilation resulted in Bronchopulmonary
  Dysplasia (oxygen toxicity) Northway (1967)
• No antenatal testing for lung maturation
  (Gluck, 1971)
• No antenatal corticosteroids (Liggins 1972)
• No surfactant treatments (Fujuwara 1980)
• No effective therapy other than supplemental
  oxygen

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Information about HMD in Late 1960s

• Atelectasis in HMD interfered with oxygenation
• Normal lungs contained surfactant (Clements
  1957)
• HMD lungs were surfactant deficient (Avery and
  Mead 1959)
• Intubation of HMD infants abolished grunting and
  decreased oxygenation (Harrison, et al., 1968)
• Ventilation with a long Ti increased oxygenation
  (Smith, et al., 1969)

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Pediatr, 1968
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5 Infants tested for change in Oxygenation with
Intubation - on 90-95 Oxygen
PaO2 Values PaO2 Values PaO2 Values
Before Intubated Intubated Extubated
91 91 61 58 93 92
1.80.4 kg Pco2517 plt0.001 1.80.4 kg Pco2517 plt0.001 1.80.4 kg Pco2517 plt0.001
Harrison, et al., Pediatr, 1968
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Nasal Piece and Fleish Tube used for PFT
Measurements
Fig. 1. Fleisch 00 Pnumotachograph, T-junction,
and nasal piece.
Harrison, et al., Pediatr, 1968
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Abstract for SPR/APS Meeting 1970
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20 Infants Treated with CPAP over 16 Months
51 Infants with IRDS
UA lines, O2 for Pao2 of 50-70 mmHg
20 - Required 100 or had Apnea
5 - Apnic at Birth
1 - Ventilated from Birth
25 - Increased O2 Only
All Survived
Bag Mask Ventilation
Ventilated
1 Survived
CPAP
All Died
16 Survived
Data from Gregory NEJM, 1971
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CPAP Device for use with Endotracheal Tube
Gregory, et al., NEJM, 1971
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CPAP Device for use with Endotracheal Tube
Gregory, et al., NEJM, 1971
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Head Box for CPAP without Endotracheal Tube
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Gregory, et al., NEJM, 1971
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CPAP
Provided by G. Gregory
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Provided by A. Wilkinson
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(No Transcript)
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From Gregory, et al., NEJM - 1971

• We did not consider an elevation in Paco2 to be
  an indicator for mechanical ventilation as long
  as pH was greater than 7.20.
• Footnote for physiologic data
• Order NAPS document 01448 from National Auxiliary
  Publications Service (the physiologic data has
  been lost)

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CPAP Worked and Rapid Innovation Occurred

• Continuous negative Pressure (Chernick and
  Vidyasargar 1972)
• Fanaroff, et al. (1973)
• Pressurized bag over head (Barrie, 1973)
• Mask that covers the mouth and nose (Harris,
  1972)
• Nasal CPAP (Kattwinkel, et al., 1973)
• Ventilation CPAP PEEP (Cumarassamy, et al.,
  1973)

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A Bag and Y-Connector for CPAP
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Barrie, The Lancet, 1973
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Caliumi-Pellegrini, et al., Arch Dis Child, 1974
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Cumarasamy, et al., Pediatrics, 1973
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Artificial Ventilation in HMD the use of PEEP
and CPAP
Treatment Outcomes with PEEP CPAP by Year Treatment Outcomes with PEEP CPAP by Year Treatment Outcomes with PEEP CPAP by Year Treatment Outcomes with PEEP CPAP by Year
Years 1969 1970 1971
Number of Patients Ventilated Survival Overall 36 36 53 38 58 44 46 78 74
Ventilated 23 23 70
Cumarasamy, Nussli, Vischer, Dangel Duc,
Pediatrics, 1973
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Effect of CPAP (PEEP) on Intubated and Ventilated
Infants with RDS
deLemos, McLaughlin, Robison, Schulz, Kirby,
Anesthesia Analgesia, 1973
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Nasal Prongs for CPAP
Kattwinkel, Fleming, Cha, and Fanaroff,
Pediatrics, 1973
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Nasal CPAP (2-5 cmH2O) for Infants with Apnea.
BW average 1kg, age of study 14 days
Kattwinkel, et al., J. Pediatr, 1975
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Follow-up Measurements to Evaluate Mechanical
Ventilation, Oxygen, and CPAP for Lung Damage
Ventilated CPAP
Number Birth Weight (kg) Gestational Age (weeks) Duration of Supplemental O2 gt 60 (hr) Duration of IPPV (hr) Duration of CPAP (hr) 11 1.60.2 31.70.6 3810 5610 - 8 2.20.2 34.11.1 113 - 489
Stocks and Godfrey, Pediatrics, 1976
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Airway Conductance Measured at Term and at 4-11
Months Post-Delivery
CPAP
Stocks Godfrey, Pediatrics, 1976
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Meta-Analysis of CPAP vs. No CPAP for Infants
with RDS
Outcome N- Studies N-Patients Risk Ratio 95 CI
Require Mech Vent Air Leaks BPD Death 4 4 2 4 145 165 100 165 0.66 2.62 0.87 0.66 0.50-0.86 1.28-5.36 0.33-2.31 0.45-0.97
Bancalari Sinclair, in Effective Care of the
Newborn Infant Sinclair and Bracken, 1992
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1980s through early 2000

• Ventilation replaced CPAP as primary therapy for
  RDS
• Antenatal steroids and surfactant decreased
  severity of RDS
• BPD was frequent in VLBW infants

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CPAP was used frequently for -

• Apnea of prematurity
• Post extubation after mechanical ventilation
• RDS in some locations (Columbia, Univ.
  Scandinavia)

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(No Transcript)
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Effect of a change in delivery room management
for infants lt1000g - allowing spontaneous
breathing with FRC recruitment and CPAP
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The Danish Approach to the Initiation of
Ventilation and Surfactant
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The Coin Trial
Ventilation CPAP P
N BW Intubated by 5d Surfactant by 5d 303 952 100 77 307 964 46 38
Morley, et al., NEJM, 2008 Morley, et al., NEJM, 2008 Morley, et al., NEJM, 2008 Morley, et al., NEJM, 2008
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The Coin Trial - 36 Week Outcome
Ventilation CPAP P
Pneumothorax Median Vent days Death BPD - 28d BPD - 36wk O2 Concentration at 36wk gt30 3 4 5.9 63 31 8.8 9 3 6.5 51 29 9.4 lt0.01 lt0.01 NS 0.01 NS NS
Morley, et al., NEJM, 2008 Morley, et al., NEJM, 2008 Morley, et al., NEJM, 2008 Morley, et al., NEJM, 2008
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Neonatal Bioethics The Moral Challenges of
medical Intervention

• The era of innovation and individualism
  1965-1982
• Mechanical Ventilation
• CPAP
• Total Parental Nutrition
• Regionalization
• Era of exposed ignorance 1982-1992
• The End of Medical Progress

Lantos and Meadow, Neonatal Bioethics, 2006
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CPAP in 2009 A New Enthusiasm

• Again frequently used as an initial therapy for
  RDS surfactant
• Early (delivery room) use popular and under study
• New types of CPAP
• Nasal CPAP Ventilatory assist (synchronized,
  NAVA)
• Multiple CPAP devices (NeopuF)
• High flow nasal cannula
• Variable pressure CPAP

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• My thanks to George Gregory for his help with
  this brief history of CPAP