20 Further steps First raise pressure till 8 cm H2O in steps of one cm Then raise FiO2 to 0.8 in steps of 0.05
21 Further steps Adjustment of oxygen saturation & PaO2 CPAP (cm H2O) F1O2First raise CPAP till 8 cm H2O in steps of 1 cmThen raise FiO2 to in steps of 0.05
22 Weaning Reach CPAP to 8 cm H2O Reduce FiO2 to 0.4 in steps of .05 Reduce pressure to 4 cm in steps of 1 cm H2OStop CPAP and put in oxygen hood
23 WeaningCPAP (cm H2O) F1O2Reduce F1O2 to 0.4 in steps of 0.05Then reduce CPAP to 4 cm in steps of 1 cmThen stop CPAP, put baby in oxygen hood
24 Monitoring during CPAP ClinicalRR, grunt, retractions, apnea, cyanosisHR, pulse, perfusion and BPTemperature, cold stressAbdominal girth, Urine outputCPAP device: fixation, blockage, local damagePulse oximetry: %ABG
25 Adequacy of CPAP Satisfactory cardiorespiratory status Comfortable babyNo retraction, no gruntNormal capillary refill, BPNormal saturations: 90-93%(set alarms at 88 and 95%)Normal ABG(PaO , PaCO , pH , BE±2)
26 Failure CPAP Containing retractions, grunt Recurrent apnea PaO2<50 torr at highest settingPaCO2>55 torrBaby not tolerating CPAP despite best efforts
27 Nursing care Humidity, warm the gases (34-370 C) Keep gas flow at 5-8 lit/minEnsure patency of prongsSuction mouth and nose SOSInstalling saline drops in nares helps
28 Nursing care Put orogastric tube to decompress the stomach Change prongs/circuit every third dayStabilize the head of babyEnsure asepsis
29 Nursing careBabies on CPAP canbe fed by OG tubebut with care!!!
30 Benefits-Bubble CPAPThe oscillatory pressure waveform gets transmitted into the lungs from the airway and may contribute to gas exchange, decreasing the infants work of breathing
31 Prerequisites for setting up a CPAP unit Mandatory (M)/desirable ( D)Source of air, oxygen (central/jumbo cylinders connected by a manifold) (M)CPAP machine withBlender (for control of Fio2) ( M ),provision to measure Fio2 ( D )Humidification & warmidification of gases ( M )Pressure measuring device /release valves for safety ( D )ABG machine ( D ), pulse oximeter ( M )Portabule X-ray machine ( M )Facilities to drain a pneumothorax ( M )Provision to ventilate if CPAPfails, in the unit ( D),to transport safely (M)Surfactant therapy ( D )Trained Pediatrican & Nurses (M)Support services ( D )
32 Our ObservationThe efficiency of applying continuous positive airway pressure (CPAP) by nasal route was retrospectively analyzed in 15 newborns with respiratory distress syndrome (9 uncomplicated hyaline membrane disease, 1 hyaline membrane disease with cardiac complication, 3 meconium aspiration syndrom, 2 transient techypnoea of newborn )Who underwent nasal CPAP treatment in oil India hospital Duliajan, Assam from to out of 9 cases of uncomplicated HMD were successfully treated with CPAP. They showed a significant improvement. The remaining 6 newborn in this group (6/15), 3 had to be intubated and mechanically ventilated owing to persistent high Fio2 (2), technical difficulties (1).2 of 3 meconium aspiration syndrome baby needed mechanical ventilation. Both TTN cases were doing well in nasal CPAP. Two of these 15 cases died, one of cerebral haemorrhage & another in sepsis.The nasal CPAP as described is a simple inexpensive and effective 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 meconium aspiration syndrome the result of nasal CPAP treatment were not convincing.
33 Recent clinical concept in CPAP Permissive hypercarbiaThis 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 7.2They 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.
34 A relatively safe life-saving modality with a great potential ConclusionA relatively safe life-saving modality with a great potential
35 Kinder Gentler cost effective respiratory support CPAP!