Presentation on theme: "Old CPAP is back with a bang"— Presentation transcript:
1Old CPAP is back with a bang Dr Rajesh KumarMD (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.
2Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WKN Engl J Med Jun 17;284(24):
3CPAP 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 saferOpen 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.
4Comeback 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
6CPAP alone for RDSCPAP with surfactant for RDSEarly CPAP for RDSCPAP as prophylactic therapyCPAP in post extubation periodCPAP in apnea of prematurityCPAP in other neonatal lung diseases (Pneumonia, MAS)
7Efficacy of CPAP for RDS Continuous distending pressure for respiratory distress syndrome in preterm infantsHo JJ, Subramaniam P, Henderson-Smart DJ, Davis PGCochrane Review, Last update June 2000Overall 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)].
8CPAP in RDS: How does it work ? Diminishing atelectasisImproving Functional residual capacityCorrecting ventilation-perfusion abnormalitiesDecreasing pulmonary edemaReducing intrapulmonary shunting
10CPAP Indications Premature baby with FiO2 above 0.3 with clinical distressFiO2 above 0.4Significant retractions
11Surfactant and CPAPSurfactant Therapy and Nasal Continuous Positive Airway Pressure for Newborns with Respiratory Distress Syndrome N Engl J Med 1994; 331: , Oct 20, 1994Henrik Verder, Bengt Robertson, Gorm Greisen, Finn Ebbesen, Per Albertsen, Kaare Lundstrom, Thorkild Jacobsen, for The Danish-Swedish Multicenter Study GroupConclusions 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.
12Surfactant with CPAP: Technique INSURE TechniqueIntubateSurfactantExtubate
13Surfactant use in level II Criteria for surfactant useClinical 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 > 50Unlikely candidatesBirth asphyxia.Pneumonia.Pneumothorax.Severe malformations.Prolonged ROM > 5 days.Meconium Aspiration Syndrome
14The 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.
15Early CPAP for RDSEarly versus delayed initiation of continuous distending pressure for respiratory distress syndrome in preterm infantsHo JJ, Henderson-Smart DJ, Davis PGCochrane Review, Last update Feb 2002Reduction 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)].
17Prophylactic CPAPAvoids the serious side effects related to intubation and ventilationCan prevent or decrease the severity of RDSDecreased incidence of RDS
18CPAP after extubationProphylactic CPAP is effective in preventing failure of extubation in VLBW babiesDecreased apnea, respiratory acidosisDavis P, Henderson SS. J Pediatric child health. 1999; 35(4):
19MAS and CPAPLow and medium CPAP is helpful in increasing the oxygenationPEEP does not increase the incidence of pneumothoraxFox WW, Berman LS, Downes JJ, et al. The therapeutic application of end expiratory pressure in MAS Pediatrics 56:214, 1975
20CPAP administrationNasal interfacesTechnique for pressure generation
24Fig 1. Image generated using a biomedical imaging visualization tool demonstrating measurementof the length of the nasopharynx comparedwith distances on the 3-dimensional model of theinfant’s head. The length of the nasopharynx consistentlycorrelated to the distance from the tip ofthe infant’s nose to a point below the eye at theperpendicular to the middle of the eye.
25TECHNIQUES 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
26Bubble CPAP system Indigenous Infant Bubble CPAP System Fisher and paykel Infant Bubble CPAP System