Download - Optimize Initial Respiratory Support
Bubble CPAP vs. Bubble CPAP vs. High Flow Nasal CannulaHigh Flow Nasal Cannula
Gil Urquidez, RRT-NPSGil Urquidez, RRT-NPSSupervisor, Respiratory Care Services Supervisor, Respiratory Care Services
Santa Clara Valley Medical CenterSanta Clara Valley Medical Center
Optimize Initial RespiratorySupport
Goal:Goal: To establish and maintain the VLBW infant’s respiratory efforts and functional residual capacity without injuring the lung (VVent IInduced LLung IInjury) from excessive use of positive pressure ventilation.
What is CPAP ?
Continuous Positive Airway Pressure
Technique of applying a continuous distending pressure to the lungs in a spontaneous breathing infant.
Usually< 10 cm of water pressure
5-10L humidified flow of blended air
How does it Work ?Distends the airway and alveoliMaintains lung volume in expiration/FRC
Makes breathing easierImproves gas exchange
Philosophy of use
Patience
Permissive Hypercapnea
Non invasive application
CPAP Beneficial effects immediately following Resuscitation
BenefitsDecreased requirements for Intubation Decreased requirement for high levels of inspired
OxygenDecreased Mechanical Ventilation Length of StayDecreased need of Postnatal steroids
Compared to Historical controls
P.Jegatheesan J of Perinatology 2006 26, 189 - 196
Tool-Kit Best Practice #7Optimize Initial Respiratory Support
Early use of CPAP (within 60 seconds of life)
Avoid Intubation (if possible)
Avoid prophylactic use of Surfactant in the DR
CPQCC Recommendation…
What Causes Chronic Lung Disease (CLD)?
CAUSECAUSE EFFECTEFFECT
Summary of Current Causes of CLD/BPD in VLBW
Barotrauma Volutrauma Atelectotrauma Developmentally
Impaired Alveolarization and Vascularization
Poor Nutrition Recurrent infections
Pressure Volume Repeated popping open Less alveoli
Not enough resources to grow Scarring and destruction
Why Did VMC Switch to Bubble CPAP Therapy?
Bubble Nasal CPAPCost EffectivenessLess Invasive Than A Other InterfacesTo Improve Overall OutcomesColumbia Medical Center’s Experience
CLD rates are the lowest in the country Bubble CPAP is SOLE form of Nasal CPAP.
Positive Outcomes Associated With The Change In Practice
Benefits Associated With Change In Practice
Improved Outcomes Associated With Change In Practice
VLBW survival WITHOUT significant IVH
SCVMC NICU
0102030405060708090
100
2006 2007 2008 2009 2010
VLBW
How do we create our own Bubble CPAP System?
• How do we do it?
• What equipment do we use?
• Where do we get it?
Creating our Setup• Where do we start?
• What hat to use?• Where do we get them?
Creating our Setup
• Preparing for the cannula
Creating our Setup
• Securing the cannula to the patient
Creating our Setup
• Chin straps
Creating our Setup
• Water Bottles
Creating our Setup
• Original Setup
Creating our Setup
How can we improve it!How can we improve it!
Creating our SetupCreating our Setup• Other options
Creating our SetupCreating our Setup• Other Options
Creating our SetupCreating our Setup• Other Options
Creating our Setup• Previous System
Current Set Up
New Circuit & Bubble Chamber
Multiple Sizes for Prongs/Mask
High Flow Nasal Cannula
Definition
High Flow Nasal Cannula is defined as heated humidified gas delivered at flows greater than 1lpm.
VMC defines High Flow Nasal Cannula as heated humidified gas delivered at 2lpm.
High Flow Nasal Cannula Set-Up
Cochrane Collaborative Review of High Flow Nasal Cannula 2011 Issue 5There is insufficient evidence to establish the safety or efficacy of HFNC as a form of respiratory support in the preterm infant
When used following extubation there may be a higher reintubation rate compared to NCPAP
More trials are needed
Early Weaning From NCPAP To HFNC Is Associated With Prolonged Oxygen Use
Randomized control trial
Clinically stable on < 30 % O2 for 24 hrs randomized to HFNC (2 L) or Stay on CPAP till go straight to room air.
NCAPAP N/C 2 L
Days on O2 5 14
Resp support
days10.5 18
Hany ES Early Human Development 2011
High Flow Nasal Cannula
PRO’s for HFNC UseEase of use Improved feeding and toleranceEasier nursing/patient handlingDecreased nasal septal trauma
CON’s for HFNC useLimited dataUnmeasured PEEPNo alarms
High Flow Nasal Cannula
VMC’s Position on HFNC
• High Flow Nasal Cannula usage when:• Patient fails multiple attempts off Bubble NCPAP• Is still needing more than 2lpm flow
Greg Is Not Happy with the Baby’s NCPAP Set Up
What’s wrong with this set up?
The Baby Is Agitated and Desating! What Can We Do To Fix This?
Aaahhh….I feel much better!
I Can See You!!!
Greg’s NOW a Happy Nurse!!!
A Happy Baby is a Happy Nurse And ULTIMATELY a HAPPY RTRT!!!
Conclusions
CPAP is Bubble CPAP is High Flow Nasal Cannula
Oxygen is a Drug
A. Needs Further Study
B. Good
C. Use with caution
D. Great
GoodGreat
Needs Further Study Use with Caution
MATCH the Definition on the RIGHT with the Therapy on the LEFT
Craig Ivie, Director, Respiratory Care ServicesDr. Balaji Govindaswami, Director, NICUAll Associate AttendingsAll NICU StaffMy Respiratory Care Staff
Thank Yous!!!