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Old CPAP is back with a bang Dr Rajesh Kumar MD (Paed), DM (Neo)

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Presentation on theme: "Old CPAP is back with a bang Dr Rajesh Kumar MD (Paed), DM (Neo)"— Presentation transcript:

1 Old CPAP is back with a bang Dr Rajesh Kumar MD (Paed), DM (Neo)

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 1971 Jun 17;284(24):

3 CPAP a lost art 1.Deemed ineffective in VLBW 2.? It increases the risks of IVH due to raised CO2. 3.Progress in ventilator technology making intubation and ventilation more effective and safer

4 Comeback of CPAP 1.Surfactant making management of RDS simpler. 2.Low incidence of chronic lung disease associated with use of CPAP. 3.Concept of prophylactic CPAP and minimal handling in the care of VLBW

5 Effective Simple Low cost technology CPAP

6 1.CPAP alone for RDS 2.CPAP with surfactant for RDS 3.Early CPAP for RDS 4.CPAP as prophylactic therapy 5.CPAP in post extubation period 6.CPAP in apnea of prematurity 7.CPAP in other neonatal lung diseases (Pneumonia, MAS)

7 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)]. 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 Efficacy of CPAP for RDS

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 FiO 2 above 0.3 with clinical distress FiO 2 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 32/40. Age less than 72 hours. Increasing requirements, e.g.. FiO2 > 50%, pH 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: Spizers 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 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


25 TECHNIQUES FOR PRESSURE GENERATION 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 Fisher and paykel Infant Bubble CPAP System Indigenous 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 Simple Low cost technology CPAP

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




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