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Continuous positive Airway Pressure (CPAP) Dr. A. K. Sarma OIL Hospital Duliajan.

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Presentation on theme: "Continuous positive Airway Pressure (CPAP) Dr. A. K. Sarma OIL Hospital Duliajan."— Presentation transcript:

1 Continuous positive Airway Pressure (CPAP) Dr. A. K. Sarma OIL Hospital Duliajan

2 Objectives What is CPAP What is CPAP How does it work How does it work Effects Effects When should we use it When should we use it Evidence, indications, contraindications Evidence, indications, contraindications How to use How to use Equipment, technique, monitoring, tips and weaning Equipment, technique, monitoring, tips and weaning

3 What is CPAP Continuous positive pressure during inspiratory and expiratory phase Continuous positive pressure during inspiratory and expiratory phase - CPAP in an infant breathing with his own effort - CPAP in an infant breathing with his own effort - Positive End Expiratory Pressure (PEEP) in an infant on ventilation - Positive End Expiratory Pressure (PEEP) in an infant on ventilation

4 Physiological mechanisms Recruitment of atelectatic alveoli Recruitment of atelectatic alveoli Increase in FRC Increase in FRC Improved compliance Improved compliance Decrease in airway resistance Decrease in airway resistance Conservation of surfactant Conservation of surfactant Stabilization of chest cage Stabilization of chest cage

5 Effects on Blood Gases Oxygen improves Oxygen improves Due to better FRC Due to better FRC Carbon dioxide declines* Carbon dioxide declines* Due to increased surface for gas exchange Due to increased surface for gas exchange (* In medium range of CPAP 4-7 cm H 2 O)

6 Adverse effects Pulmonary Pulmonary - Overdistension, diminished compliance - Air leaks (with ET-CPAP) Cardiovascular Cardiovascular - Increase CVP - Decrease venous return, decreased cardiac output resulting in hypotension output resulting in hypotension - Increase pulmonary vascular resistance - Metabolic acidosis

7 Adverse effects CNS CNS Increase intracranial pressure Decrease cerebral perfusion GIT GIT Bowel distension by swallowed air Decreased blood flow Kidneys Kidneys Decreased blood flow

8 Clinical Indications

9 Indications Respiratory distress Respiratory distress - RDS, HMD - TTNB, delayed adaptation - MAS, pneumonia Apneic spells Apneic spells - Apnea of prematurity Post – extubation Post – extubation Others Others - Tracheomalacia

10 Indications ET CPAP before extubation Direct extubation is associated with increased chance of successful extubation compared to ET-CPAP Direct extubation is associated with increased chance of successful extubation compared to ET-CPAP

11 Contraindications Increased pCO 2 Increased pCO 2 Recurrent apnea unresponsive to nasal CPAP Recurrent apnea unresponsive to nasal CPAP Severe cardiovascular instability Severe cardiovascular instability Upper airway abnormalities- cleft palate, choanal atresia, diaphragmatic hernia, TE fistula Upper airway abnormalities- cleft palate, choanal atresia, diaphragmatic hernia, TE fistula

12 Technique

13 Technique Nasal Nasal Nasopharyngeal Nasopharyngeal Face mask with seal Face mask with seal Headbox with seal Headbox with seal Endotracheal Endotracheal

14 Technique: nasal prongs Most effective Most effective Baby can pop off Baby can pop off Less invasive Less invasive Lesser work of breathing Lesser work of breathing But difficult to keep in place But difficult to keep in place

15 Technique: nasal prongs

16 Clinical use

17 CPAP ranges (cm H 2 O) Physiological 3 cm H 2 O ET-CPAP Nasal ET-CPAP Nasal Low Low Medium Medium High High (Add 1 cm extra for nasal CPAP)

18 CPAP ranges (cm H 2 O) CPAP of < 3 cm H 2 O never given! CPAP of < 3 cm H 2 O never given! CPAP of 4-7 cm H 2 O is good range. CPAP of 4-7 cm H 2 O is good range. Advantage many, disadvantage few Advantage many, disadvantage few CPAP of over 8 cm H 2 O is a bad range CPAP of over 8 cm H 2 O is a bad range Advantage some, disadvantage galore! Advantage some, disadvantage galore!

19 Initiation Pressure : 5-6 cm H 2 O Pressure : 5-6 cm H 2 O FiO 2 : 0.4 – 0.5 FiO 2 : 0.4 – 0.5

20 Further steps First raise pressure till 8 cm H 2 O in steps of one cm First raise pressure till 8 cm H 2 O in steps of one cm Then raise FiO 2 to 0.8 in steps of 0.05 Then raise FiO 2 to 0.8 in steps of 0.05

21 Further steps Adjustment of oxygen saturation & PaO 2 CPAP (cm H 2 O) F 1 O 2 CPAP (cm H 2 O) F 1 O First raise CPAP till 8 cm H 2 O in steps of 1 cm First raise CPAP till 8 cm H 2 O in steps of 1 cm Then raise FiO 2 to in steps of 0.05 Then raise FiO 2 to in steps of 0.05

22 Weaning Reach CPAP to 8 cm H 2 O Reduce FiO 2 to 0.4 in steps of.05 Reduce pressure to 4 cm in steps of 1 cm H 2 O Stop CPAP and put in oxygen hood

23 Weaning CPAP (cm H 2 O) F 1 O Reduce F 1 O 2 to 0.4 in steps of 0.05 Reduce F 1 O 2 to 0.4 in steps of 0.05 Then reduce CPAP to 4 cm in steps of 1 cm Then reduce CPAP to 4 cm in steps of 1 cm Then stop CPAP, put baby in oxygen hood Then stop CPAP, put baby in oxygen hood

24 Monitoring during CPAP Clinical RR, grunt, retractions, apnea, cyanosis RR, grunt, retractions, apnea, cyanosis HR, pulse, perfusion and BP HR, pulse, perfusion and BP Temperature, cold stress Temperature, cold stress Abdominal girth, Urine output Abdominal girth, Urine output CPAP device: fixation, blockage, local damage CPAP device: fixation, blockage, local damage Pulse oximetry: 90-93% ABG

25 Adequacy of CPAP Satisfactory cardiorespiratory status Comfortable baby Comfortable baby No retraction, no grunt No retraction, no grunt Normal capillary refill, BP Normal capillary refill, BP Normal saturations: 90-93% Normal saturations: 90-93% (set alarms at 88 and 95%) (set alarms at 88 and 95%) Normal ABG Normal ABG (PaO , PaCO , pH , BE±2) (PaO , PaCO , pH , BE±2)

26 Failure CPAP Containing retractions, grunt Containing retractions, grunt Recurrent apnea Recurrent apnea PaO2<50 torr at highest setting PaO2<50 torr at highest setting PaCO2>55 torr PaCO2>55 torr Baby not tolerating CPAP despite best efforts Baby not tolerating CPAP despite best efforts

27 Nursing care Humidity, warm the gases ( C) Humidity, warm the gases ( C) Keep gas flow at 5-8 lit/min Keep gas flow at 5-8 lit/min Ensure patency of prongs Ensure patency of prongs Suction mouth and nose SOS Suction mouth and nose SOS Installing saline drops in nares helps Installing saline drops in nares helps

28 Nursing care Put orogastric tube to decompress the stomach Put orogastric tube to decompress the stomach Change prongs/circuit every third day Change prongs/circuit every third day Stabilize the head of baby Stabilize the head of baby Ensure asepsis Ensure asepsis

29 Nursing care Babies on CPAP can be fed by OG tube but with care!!! but with care!!!

30 Benefits-Bubble CPAP The oscillatory pressure waveform gets transmitted into the lungs from the airway and may contribute to gas exchange, decreasing the infants work of breathing The 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 with Blender (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 Observation The 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 hypercarbia This is a strategy of Babies & Childrens 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.

34 Conclusion A relatively safe life-saving modality with a great potential

35 Kinder Gentler cost effective respiratory support CPAP!

36 Thank You


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