Continuous Continuous positive Airway positive Airway

Pressure (CPAP)Pressure (CPAP)

Dr. A. K. SarmaDr. A. K. Sarma

OIL HospitalOIL Hospital

DuliajanDuliajan

ObjectivesObjectives What is CPAPWhat is CPAP

How does it work How does it work

EffectsEffects

When should we use itWhen should we use it

Evidence, indications, contraindicationsEvidence, indications, contraindications

How to useHow to use

Equipment, technique, monitoring, tips and weaningEquipment, technique, monitoring, tips and weaning

What is CPAPWhat is CPAP

Continuous positive pressure during Continuous positive pressure during inspiratory and inspiratory and expiratoryexpiratory phase phase

- CPAP in an infant breathing with his own - CPAP in an infant breathing with his own efforteffort

- Positive End Expiratory Pressure (PEEP) in - Positive End Expiratory Pressure (PEEP) in an an infant on ventilationinfant on ventilation

Physiological Physiological mechanismsmechanisms

Recruitment of atelectatic Recruitment of atelectatic alveolialveoli

Increase in FRCIncrease in FRC Improved complianceImproved compliance Decrease in airway resistanceDecrease in airway resistance Conservation of surfactantConservation of surfactant Stabilization of chest cageStabilization of chest cage

Effects on Blood GasesEffects on Blood Gases

Oxygen improvesOxygen improves

Due to better FRCDue to better FRC

Carbon dioxide declines*Carbon dioxide declines*

Due to increased surface for gas exchangeDue to increased surface for gas exchange

(* In medium range of CPAP 4-7 cm H(* In medium range of CPAP 4-7 cm H22O)O)

Adverse effectsAdverse effects PulmonaryPulmonary

- Overdistension, diminished compliance- Overdistension, diminished compliance- Air leaks (with ET-CPAP)- Air leaks (with ET-CPAP)

CardiovascularCardiovascular- Increase CVP- Increase CVP- Decrease venous return, decreased cardiac- Decrease venous return, decreased cardiac output resulting in hypotensionoutput resulting in hypotension- Increase pulmonary vascular resistance- Increase pulmonary vascular resistance- Metabolic acidosis- Metabolic acidosis

Adverse effectsAdverse effects

CNSCNSIncrease intracranial pressureIncrease intracranial pressureDecrease cerebral perfusionDecrease cerebral perfusion

GITGITBowel distension by swallowed airBowel distension by swallowed airDecreased blood flowDecreased blood flow

KidneysKidneysDecreased blood flowDecreased blood flow

Clinical IndicationsClinical Indications

IndicationsIndications Respiratory distressRespiratory distress

- RDS, HMD- RDS, HMD- TTNB, delayed adaptation- TTNB, delayed adaptation- MAS, pneumonia- MAS, pneumonia

Apneic spellsApneic spells- Apnea of prematurity- Apnea of prematurity

Post – extubationPost – extubation

OthersOthers- Tracheomalacia - Tracheomalacia

IndicationsIndications

ET CPAP before extubationET CPAP before extubation

Direct extubation is associated with increased Direct extubation is associated with increased chance of successful extubation compared to chance of successful extubation compared to ET-CPAPET-CPAP

ContraindicationsContraindications

Increased pCOIncreased pCO22

Recurrent apnea unresponsive to nasal CPAPRecurrent apnea unresponsive to nasal CPAP Severe cardiovascular instabilitySevere cardiovascular instability Upper airway abnormalities- cleft palate, Upper airway abnormalities- cleft palate,

choanal atresia, diaphragmatic hernia, TE choanal atresia, diaphragmatic hernia, TE fistulafistula

TechniqueTechnique

TechniqueTechnique

NasalNasal NasopharyngealNasopharyngeal Face mask with sealFace mask with seal Headbox with sealHeadbox with seal EndotrachealEndotracheal

Technique: nasal prongsTechnique: nasal prongs

Most effectiveMost effective Baby can pop offBaby can pop off Less invasiveLess invasive Lesser work of breathingLesser work of breathing But difficult to keep in placeBut difficult to keep in place

Technique: nasal prongsTechnique: nasal prongs

Clinical useClinical use

CPAP ranges (cm HCPAP ranges (cm H22O)O)

Physiological 3 cm HPhysiological 3 cm H22OO

ET-CPAP NasalET-CPAP Nasal Low 3-4 4-5Low 3-4 4-5 MediumMedium 5-7 6-8 5-7 6-8 HighHigh 8-10 9-11 8-10 9-11

(Add 1 cm extra for nasal CPAP)(Add 1 cm extra for nasal CPAP)

CPAP ranges (cm HCPAP ranges (cm H22O)O)

CPAP of < 3 cm HCPAP of < 3 cm H22O never given!O never given!

CPAP of 4-7 cm HCPAP of 4-7 cm H22O is good range.O is good range.

Advantage many, disadvantage few Advantage many, disadvantage few

CPAP of over 8 cmCPAP of over 8 cm HH22O is a bad rangeO is a bad range

Advantage some, disadvantage galore!Advantage some, disadvantage galore!

InitiationInitiation

Pressure : 5-6 cm Pressure : 5-6 cm HH22OO

FiOFiO2 2 : 0.4 – : 0.4 – 0.50.5

Further stepsFurther steps

First raise pressure till 8 cm HFirst raise pressure till 8 cm H22O O in steps of one cmin steps of one cm

Then raise Then raise FiOFiO2 2 to 0.8 in steps to 0.8 in steps of 0.05of 0.05

Further stepsFurther stepsAdjustment of oxygen saturation & PaOAdjustment of oxygen saturation & PaO22

CPAP (cm HCPAP (cm H22O)O) FF11OO22

55 0.50.5 66 0.50.5

77 0.50.5 88 0.50.5 8 8 0.60.6 8 8 0.70.7 8 8 0.80.8

• First raise CPAP till 8 cm HFirst raise CPAP till 8 cm H22O in steps of 1 cmO in steps of 1 cm• Then raise FiOThen raise FiO2 2 to in steps of 0.05to in steps of 0.05

WeaningWeaning

Reach CPAP to 8 cm HReach CPAP to 8 cm H22OO

Reduce FiOReduce FiO2 2 to 0.4 in steps of .05to 0.4 in steps of .05

Reduce pressure to 4 cm in steps of 1 cm HReduce pressure to 4 cm in steps of 1 cm H22OO

Stop CPAP and put in oxygen hoodStop CPAP and put in oxygen hood

WeaningWeaningCPAP (cm HCPAP (cm H22O)O) FF11OO22

8 8 0.70.7

88 0.60.6 88 0.50.5 88 0.40.4 77 0.40.4 66 0.40.4 55 0.40.4 44 0.4 0.4

• Reduce FReduce F11OO22 to 0.4 in steps of 0.05 to 0.4 in steps of 0.05• Then reduce CPAP to 4 cm in steps of 1 cmThen reduce CPAP to 4 cm in steps of 1 cm• Then stop CPAP, put baby in oxygen hoodThen stop CPAP, put baby in oxygen hood

Monitoring during CPAPMonitoring during CPAP

ClinicalClinical• RR, grunt, retractions, apnea, cyanosisRR, grunt, retractions, apnea, cyanosis• HR, pulse, perfusion and BPHR, pulse, perfusion and BP• Temperature, cold stressTemperature, cold stress• Abdominal girth, Urine outputAbdominal girth, Urine output• CPAP device: fixation, blockage, local damageCPAP device: fixation, blockage, local damage

Pulse oximetry: 90-93%Pulse oximetry: 90-93%

ABGABG

Adequacy of CPAPAdequacy of CPAP

Satisfactory cardiorespiratory statusSatisfactory cardiorespiratory status• Comfortable babyComfortable baby• No retraction, no gruntNo retraction, no grunt• Normal capillary refill, BPNormal capillary refill, BP• Normal saturations: 90-93%Normal saturations: 90-93% (set alarms at 88 and 95%)(set alarms at 88 and 95%)

• Normal ABGNormal ABG

(PaO(PaO22 60-80, PaCO 60-80, PaCO22 40-50, pH 7.35-7.45, BE 40-50, pH 7.35-7.45, BE±2)±2)

Failure CPAPFailure CPAP

Containing retractions, gruntContaining retractions, grunt Recurrent apneaRecurrent apnea PaO2<50 torr at highest settingPaO2<50 torr at highest setting PaCO2>55 torr PaCO2>55 torr Baby not tolerating CPAP despite best Baby not tolerating CPAP despite best

effortsefforts

Nursing careNursing care

Humidity, warm the gases (34-37Humidity, warm the gases (34-370 0 C)C)

Keep gas flow at 5-8 lit/minKeep gas flow at 5-8 lit/min Ensure patency of prongsEnsure patency of prongs Suction mouth and nose SOSSuction mouth and nose SOS Installing saline drops in nares helpsInstalling saline drops in nares helps

Nursing careNursing care

Put orogastric tube to decompress the Put orogastric tube to decompress the stomachstomach

Change prongs/circuit every third dayChange prongs/circuit every third day Stabilize the head of babyStabilize the head of baby Ensure asepsisEnsure asepsis

Nursing careNursing careBabies on CPAP can Babies on CPAP can

be fed by OG tubebe fed by OG tube

but with care!!!but with care!!!

Benefits-Bubble CPAPBenefits-Bubble CPAP

The oscillatory pressure waveform gets The oscillatory pressure waveform gets transmitted into the lungs from the airway transmitted into the lungs from the airway and may contribute to gas exchange, and may contribute to gas exchange, decreasing the infants work of breathing decreasing the infants work of breathing

Prerequisites for setting up a CPAP unitPrerequisites for setting up a CPAP unit

Mandatory (M)/desirable ( D)Mandatory (M)/desirable ( D)Source of air, oxygen (central/jumbo cylinders connected by a manifold) (M)Source of air, oxygen (central/jumbo cylinders connected by a manifold) (M) CPAP machine withCPAP machine with

Blender (for control of Fio2) ( M ),provision to measure Fio2 ( D )Blender (for control of Fio2) ( M ),provision to measure Fio2 ( D )Humidification & warmidification of gases ( M )Humidification & warmidification of gases ( M )Pressure measuring device /release valves for safety ( D )Pressure measuring device /release valves for safety ( D )

ABG machine ( D ), pulse oximeter ( M )ABG machine ( D ), pulse oximeter ( M )

Portabule X-ray machine ( M )Portabule X-ray machine ( M )

Facilities to drain a pneumothorax ( M )Facilities to drain a pneumothorax ( M )

Provision to ventilate if CPAPfails, in the unit ( D),to transport safely (M)Provision to ventilate if CPAPfails, in the unit ( D),to transport safely (M)

Surfactant therapy ( D )Surfactant therapy ( D )

Trained Pediatrican & Nurses (M)Trained Pediatrican & Nurses (M)Support services ( D )Support services ( D )

Our Observation Our Observation The efficiency of applying continuous positive airway pressure The efficiency of applying continuous positive airway pressure

(CPAP) by nasal route was retrospectively analyzed in 15 newborns with (CPAP) by nasal route was retrospectively analyzed in 15 newborns with respiratory distress syndrome (9 uncomplicated hyaline membrane respiratory distress syndrome (9 uncomplicated hyaline membrane disease, 1 hyaline membrane disease with cardiac complication, 3 disease, 1 hyaline membrane disease with cardiac complication, 3 meconium aspiration syndrom, 2 transient techypnoea of newborn )meconium aspiration syndrom, 2 transient techypnoea of newborn )

Who underwent nasal CPAP treatment in oil India hospital Duliajan, Who underwent nasal CPAP treatment in oil India hospital Duliajan, Assam from 01-12-2006 to 31-11-2007. 7 out of 9 cases of uncomplicated Assam from 01-12-2006 to 31-11-2007. 7 out of 9 cases of uncomplicated HMD were successfully treated with CPAP. They showed a significant HMD were successfully treated with CPAP. They showed a significant improvement. The remaining 6 newborn in this group (6/15), 3 had to be improvement. The remaining 6 newborn in this group (6/15), 3 had to be intubated and mechanically ventilated owing to persistent high Fio2 (2), intubated and mechanically ventilated owing to persistent high Fio2 (2), technical difficulties (1).technical difficulties (1).

2 of 3 meconium aspiration syndrome baby needed mechanical 2 of 3 meconium aspiration syndrome baby needed mechanical ventilation. Both TTN cases were doing well in nasal CPAP. Two of these ventilation. Both TTN cases were doing well in nasal CPAP. Two of these 15 cases died, one of cerebral haemorrhage & another in sepsis.15 cases died, one of cerebral haemorrhage & another in sepsis.

The nasal CPAP as described is a simple inexpensive and effective The nasal CPAP as described is a simple inexpensive and effective method of applying CPTPP in newborn with uncomplicated HMD, except method of applying CPTPP in newborn with uncomplicated HMD, except radiological stage IV. In TTN it is an excellent modality but in RDS due to radiological stage IV. In TTN it is an excellent modality but in RDS due to meconium aspiration syndrome the result of nasal CPAP treatment were meconium aspiration syndrome the result of nasal CPAP treatment were not convincing.not convincing.

Recent clinical concept in CPAP

Permissive hypercarbia

This is a strategy of Babies & Children’s Hospital. Columbia University, New York. The strategy involves use of bubble CPAP in early course of respiratory distress in both preterm & term babies, the clinicians accept hypercapnia – PCO2 levels up to 60 or higher and PaO2 levels low 50 or even lower and pH levels as low as 7.2

They have shown lesser need for mechanical ventilation (75 vs 29%) and surfactant therapy (45 vs 10%) when compare to VLBW babies managed at Boston. The mortality rate on both strategies were similar, but the incidence of CLD far lower in the bubble CPAP – Columbia NICU (4% vs 22% at Boston) Long term pulmonary and neurological outcomes have not been studied / compared.

ConclusionConclusionA relatively safe life-saving modality with a A relatively safe life-saving modality with a

great potentialgreat potential

Kinder Gentler cost effective Kinder Gentler cost effective respiratory supportrespiratory support

CPAP!CPAP!

Thank YouThank You