1. How continuous positive airway pressure (CPAP) is currently being used – an overview C. C. Roehr, G. Schmalisch, R. Wauer Charité Universitätsmedizin Berlin Germany

2. INCA/Hudson Neo-Fit „Kniewasser“ System Infant-Flow driver F&P Bubble CPAP Mono-nasales Tubus CPAP Long and short binasal prongs Beneviste valve

3. Neo-Fit „Kniewasser System Infant-Flow driver F&P Bubble CPAP Mono-nasal CPAP Longe and short binasal prongs How is CPAP being used in neonatal medicine? How is CPAP being used in neonatal medicine?INCA/Hudson

4. Use of CPAP in German, Austrian and Swiss neonatal units for which clinical purpose? for which clinical purpose? when used as primary therapy? when used as primary therapy? what CPAP-system used? what CPAP-system used? mono- or bi-nasal? mono- or bi-nasal? CPAP use in the delivery room CPAP use in the delivery room differences between levels of care? differences between levels of care? flow and CPAP-level flow and CPAP-level

5. Methods Questionnaire studyQuestionnaire study German national survey and internatinal survey (FRG, A, Ch)German national survey and internatinal survey (FRG, A, Ch) all maximum level NICU and paediatr. Hospitalsall maximum level NICU and paediatr. Hospitals mailed questionnairemailed questionnaire telephone interviewtelephone interview Statistical analysis (Statgraph®)Statistical analysis (Statgraph®)

6. Methods Data-Analysis MS Excell / StatgraphicsPostal reminder after 4 weeks International (FRG, A, Ch) survey of all level 3 NICU Telephone interviewMailed questionnaire Nation wide survey of all NICU (level 1-3)

7. Response reminder n = 127 (47%) Contacted institutions n = 274 Surveyed institutions Response 1st questionnaier n = 147 (53%) Reponse to questionnair Telphone contact n = 70 (26%) Response to tel. contact Results German survey Roehr C et al. 2007

8. Response reminder n = 127 (47%) Contatced institiutions n = 274 Surveyed institutions Response 1st questionnaire n = 147 (53%) Reponse to questionnair Telephone contact n = 70 (26%) Response to tel. contact Results German survey positive answer n = 218 (79%) Roehr C et al. 2007

9. Response reminder n = 127 (47%) Contatced institutions n = 274 Surveyed institutions Response 1st questionnaire n = 147 (53%) Reponse to questionnair Telephone contact n = 70 (26%) Response to tel. contact Results German survey positive answer n = 218 (79%) No aswer n = 57 (21%) Roehr C et al. 2007

10. Characteristics of institutions n Admissions per year* (Mean and (Range) <10 ventilator beds >10 ventilator beds 85 259 (20- 1000) 75 (89%) 7 (11%) 110 312 (50- 1000) 93 (85%) 16 (15%) 23393(180-1100) 6 (27%) 16 (73%) Total218 *p = 0.014 Primary paed. care Secondary paed. care Tertiary paediatric care

11. Patients < 1500g/year No. Admissions BW < 1500 g Primary care hosp. Secondary caretertiary care hospital p<0.0001 between institutions Institution

12. No sign. difference in CPAP use across institutions n Guideline CPAP use CPAP - post ex- tubation CPAP – ADS Primary paed. care 85 57 % 95 % 93 % Secondary paed. care 110 97 % Tertiary paediatric care 23 100 % p = 0,13 0,57 0,460,28 95 % 53 % 74 % CPAP - Apnoea- Bradycardia- Syndrome 98 % 96 % 100 %

13. Mono-, bi-nasal, or both CPAP-systems? Differences between institutions not statist. significant

14. Use of CPAP as commercial system, composite system or custom made Commercial system Composite Systems Custom made system Roehr C et al. Eur J Med Res 2007: 12; 139-44

15. Infant flow driver (EME) 36% 26% 13% 9% Fisher & Paykel Roehr C et al. Eur J Med Res 2007: 12; 139-44 CPAP generators used in German NICUs

16. Maximum tolerated CPAP 56789 -12 CPAP in cmH 2 O Median 7 cmH 2 O n Differences between institutions not statist. significant

17. Flow under CPAP Frequency (%) 4.5 - 5.5 8 - 9 6 - 71 to 4 L/min Median 6 L/min Differences between institutions not statist. significant

18. 2nd investigation: A survey of neonatal units of German speaking countries

19. International survey FRG, A, CH Units approached with 1st questionnaire n = 249 100% 2nd questionnaire n = 123 49% Telephone interview n = 25 10% Total recall 188/24975% Stepwise approach of tertiary neonatal units

20. Results: CPAP in DR *no statistical difference between regions, univ. or non-univ. neonatal units *no statistical difference between regions, univ. or non-univ. neonatal units 97 in percent (%)

21. Summary Wide spectrum of clinical appliactionsWide spectrum of clinical appliactions –RDS –Apnoea-Bradycardia-Syndrome and –post-extubation parallel use of low-flow (bubble) CPAP, high-flow and respirator generated CPAPparallel use of low-flow (bubble) CPAP, high-flow and respirator generated CPAP Heterogeneity of flow and CPAP-levelsHeterogeneity of flow and CPAP-levels CPAP in DR used with and without prolonged inflationsCPAP in DR used with and without prolonged inflations

22. Conclusion Use of CPAP in German speaking countries is not standardized Use of CPAP in German speaking countries is not standardized We believe this may reflect gaps in knowledge on the potentials of CPAP, as well as lack of sound evidence for specific areas of CPAP therapy We believe this may reflect gaps in knowledge on the potentials of CPAP, as well as lack of sound evidence for specific areas of CPAP therapy  further clinical studies are needed. Educational opportunities to learn about CPAP should be widely offered.