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Old CPAP is back with a bang

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Presentation on theme: "Old CPAP is back with a bang"— Presentation transcript:

1 Old CPAP is back with a bang
Dr Rajesh Kumar MD (Paed), DM (Neo) Selling your ideas is challenging. First, you must get your listeners to agree with you in principle. Then, you must move them to action. Use the Dale Carnegie Training® Evidence – Action – Benefit formula, and you will deliver a motivational, action-oriented presentation.

2 Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK N Engl J Med Jun 17;284(24):

3 CPAP a lost art Deemed ineffective in VLBW
? It increases the risks of IVH due to raised CO2. Progress in ventilator technology making intubation and ventilation more effective and safer Open your presentation with an attention-getting incident. Choose an incident your audience relates to. The incidence is the evidence that supports the action and proves the benefit. Beginning with a motivational incident prepares your audience for the action step that follows.

4 Comeback of CPAP Surfactant making management of RDS simpler.
Low incidence of chronic lung disease associated with use of CPAP. Concept of prophylactic CPAP and minimal handling in the care of VLBW

5 Effective CPAP Low cost technology Simple

6 CPAP alone for RDS CPAP with surfactant for RDS Early CPAP for RDS CPAP as prophylactic therapy CPAP in post extubation period CPAP in apnea of prematurity CPAP in other neonatal lung diseases (Pneumonia, MAS)

7 Efficacy of CPAP for RDS
Continuous distending pressure for respiratory distress syndrome in preterm infants Ho JJ, Subramaniam P, Henderson-Smart DJ, Davis PG Cochrane Review, Last update June 2000 Overall mortality [RR 0.52 (0.32, 0.87), NNT 7 (4, 25)] Mortality in birth weights above 1500 g [RR 0.24 (0.07, 0.84), NNT 4 (2, 13)].

8 CPAP in RDS: How does it work ?
Diminishing atelectasis Improving Functional residual capacity Correcting ventilation-perfusion abnormalities Decreasing pulmonary edema Reducing intrapulmonary shunting

9 CPAP In RDS: guidelines

10 CPAP Indications Premature baby with
FiO2 above 0.3 with clinical distress FiO2 above 0.4 Significant retractions

11 Surfactant and CPAP Surfactant Therapy and Nasal Continuous Positive Airway Pressure for Newborns with Respiratory Distress Syndrome N Engl J Med 1994; 331: , Oct 20, 1994 Henrik Verder, Bengt Robertson, Gorm Greisen, Finn Ebbesen, Per Albertsen, Kaare Lundstrom, Thorkild Jacobsen, for The Danish-Swedish Multicenter Study Group Conclusions In babies with moderate-to-severe respiratory distress syndrome treated with nasal continuous positive airway pressure, a single dose of surfactant reduced the need for subsequent mechanical ventilation.

12 Surfactant with CPAP: Technique
INSURE Technique Intubate Surfactant Extubate

13 Surfactant use in level II
Criteria for surfactant use Clinical and/or radiological evidence of RDS. Gestational age ³ 32/40. Age less than 72 hours. Increasing requirements, e.g.. FiO2 > 50%, pH < 7.25, PaO2 < 50, PaCO2 > 50 Unlikely candidates Birth asphyxia. Pneumonia. Pneumothorax. Severe malformations. Prolonged ROM > 5 days. Meconium Aspiration Syndrome

14 The milder the RDS, the sooner the infant will find himself in 100% oxygen and maximal ventilatory support. Spitzer A: Spizer’s law of neonatology. Cin Pediatr 20: 733, 1981.

15 Early CPAP for RDS Early versus delayed initiation of continuous distending pressure for respiratory distress syndrome in preterm infants Ho JJ, Henderson-Smart DJ, Davis PG Cochrane Review, Last update Feb 2002 Reduction in IPPV use in the early CPAP [RR 0.55 (0.32, 0.96), NNT 6 (4, 33)]. Trend for decreased mortality [RR 0.68 (0.34, 1.38)].

16 Acta Paediatr 1993 Nov;82(11):934-8
Prophylactic CPAP Acta Paediatr 1993 Nov;82(11):934-8 "Minitouch" treatment of very low-birth-weight infants. Jacobsen T, Gronvall J, Petersen S, Andersen GE.

17 Prophylactic CPAP Avoids the serious side effects related to intubation and ventilation Can prevent or decrease the severity of RDS Decreased incidence of RDS

18 CPAP after extubation Prophylactic CPAP is effective in preventing failure of extubation in VLBW babies Decreased apnea, respiratory acidosis Davis P, Henderson SS. J Pediatric child health. 1999; 35(4):

19 MAS and CPAP Low and medium CPAP is helpful in increasing the oxygenation PEEP does not increase the incidence of pneumothorax Fox WW, Berman LS, Downes JJ, et al. The therapeutic application of end expiratory pressure in MAS Pediatrics 56:214, 1975

20 CPAP administration Nasal interfaces Technique for pressure generation

21 Nasal interfaces

22 Nasal interfaces

23 Nasopharyngeal ET tube

24 Fig 1. Image generated using a biomedical imaging
visualization tool demonstrating measurement of the length of the nasopharynx compared with distances on the 3-dimensional model of the infant’s head. The length of the nasopharynx consistently correlated to the distance from the tip of the infant’s nose to a point below the eye at the perpendicular to the middle of the eye.

Expiratory flow valve (e.g. ventilator) Underwater tube 'bubble' CPAP (underwater expiratory resistance) Benveniste device (pressure generation at nasal level: gas jet device connected to nasal prong/s) Infant Flow Driver (IFD) system (pressure generation in Infant Flow 'Generator' at nasal level

26 Bubble CPAP system Indigenous Infant Bubble CPAP System
Fisher and paykel Infant Bubble CPAP System

27 Levels of CPAP

28 Failure of CPAP PaO2 <50 mm Hg in 100% oxygen at pressure cm H2O If nasal CPAP fails, ET CPAP can be tried IPPV if PaO2 is <50 mm Hg or pH <7.25

29 Effective CPAP Low cost technology Simple

30 Summary CPAP is simple and effective low cost technology
Apply CPAP early in RDS Whenever in doubt use CPAP Need for increasing the awareness for the use of CPAP and Surfactant

31 Thank You



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