CPAP%20

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CPAP A GENTLE VENTILATION

• DR ASHOK MODI
• MD, DNB, MRCP(UK)
• CONSULTANT NEONATAL INTENSIVIST
• Bhagirathi Neotia Woman Child Care Centre

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CONTENTS

• Introduction
• Historical aspects
• How it works
• Methods
• Indications
• Weaning
• Adverse effects

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Introduction

• Respiratory distress in a just born baby- bad
  news!
• For doctors Inconvenience, complications(BPD)
• More so for family death, handicap, cost
• Solution CPAP
• Doctors convenient, less likely to go wrong
• Family baby saved, low cost
• Do I need to tell more?
• Continuous distending pressure to upper lower
  airways, spontaneously breathing, throughout

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What is CPAP ?

• A technique of airway Management in which -
• 1. Positive intrapulmonary pressure is applied
  artificially to the airways , whereby Distending
  Pressure is created in the Alveoli
• 2. Spontaneously breathing baby
• 3. Throughout the respiratory cycle

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Historical aspects

• Harrison 1st increased alveolar pressure
  during expiration in RDS Abolition of the grunt
  in RDS deterioration
• Gregory et al(1971) used CPAP 1st in
  spontaneously breathing neonate in RDS
• Last 3 decades long way to newer devices with
  better knowledge of physiology bio-physics

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What does it do?

• Prevents alveolar atelectasis, enhances
  maintains FRC
• Decreases total airway resistance
• Regularises breathing pattern
• Improvement in surfactant metabolism
• Splints chest wall, airways Pharynx
• Reduces work of breathing

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What does it do?

• Results in reopening of collapsed/unstable
  alveoli -
• Increased surface area for gas exchange
• Preserves surfactant esp if applied early
• Prevents Intrapulmonary shunting
• Net result improved oxygenation ventilation

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How to deliver CPAP

• Delivery of continuous positive airway pressure
  requires 3 components
• 1. Flow circuit(warm humidified)
• 2. An airway interface
• 3. A positive pressure system

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Airway Interface

• Single nasal prongs
• Binasal prongs(Short Long)
• Nasopharyngeal prongs
• Endotracheal tube
• Head boxes, nasal cannulae, face masks
• Short binasal prongs most effective, least
  invasive

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Positive pressure system

• Fluid column(Bubble CPAP)
• Resistance applied at the expiratory valve e.g
  Draeger / Ventilator
• Pressure generation at nasal level
• CPAP generation in the immediate vicinity of
  nasal airway by converting kinetic energy e.g
  Infant flow driver

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DEVICES

• Infant Flow Driver unique fluid
  mechanics(fluidic flip action)
• Bubble CPAP oscillatory vibrations
• Infant Ventilator with CPAP mode
• Which is the best?

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Optimal pressure

• No compelling Data
• Traditional 4 6 cm of water
• However some studies as high as 10 cm H2O
• Tailored to babys needs
• Increments by 1 cm of water
• Guided by CXR

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INDICATIONS

• Mild to moderate RDS
• Apnoea of prematurity
• After extubation
• Alternative to mechanical ventilation
• ( INSURE)
• Presence of poorly expanded or infiltrated lung
  fields on CXR
• Tracheomalacia or abnormalities of lower airways

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CONTRA-INDICATIONS

• Definite need for intubation Ventilation
• Upper airway anomaly e.g choanal atresia, cleft
  lip palate, TOF
• Cardiovascular instability impending arrest
• Unstable respiratory drive
• Untreated CDH
• When CPAP is failing
• Bronchiolitis

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Monitoring Care

• Minimal handling/Sedation
• Nasal prongs of right size in place(FIXATION)
• Orogastric tube
• Care of the nares
• Change of posture
• Vitals Continuous pulse oximetry
• Blood gas, haematological, radiological
  biochemical monitoring

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Is CPAP Helping?

• Reduction in respiratory rate
• Stabilization or reduction in Fio2
• Resolution of grunting
• Reduction in degree of sternal intercostal
  recession

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When is CPAP failing

• Recurrent apnoeic attacks
• Spontaneous episodes of desaturation
• Increasing oxygen requirements
• Worsening respiratory distress
• Agitation not relieved by simple measures
• Worsening blood gases

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WEANING

• Once baby very stable with minimal respiratory
  distress, normal blood gas improving CXR
• Fio2 gradually weaned to 40 50
• Then pressure decreased in steps of 1 cm of water
  until 3 4 cm

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Not without its complications

• Do not take CPAP lightly!
• Pulmonary air leaks
• Excessive pressure- compromise o2
• Abdominal distension
• Hypotension
• Local excoriation, scarring, deformity

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Setting an simple CPAP
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To conclude

• Gentle poor mans ventilation
• Easy to set up minimal training
• Save babies with RDS in developing countries vs
  headbox O2
• Lots of unanswered questions yet
• Optimal device
• Ideal pressure