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.

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):1333-40

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.

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

Effective CPAP Low cost technology Simple

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)

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)].

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

CPAP In RDS: guidelines

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

Surfactant and CPAP Surfactant Therapy and Nasal Continuous Positive Airway Pressure for Newborns with Respiratory Distress Syndrome N Engl J Med 1994; 331:1051-1055, 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.

Surfactant with CPAP: Technique INSURE Technique Intubate Surfactant Extubate

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

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.

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)].

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.

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

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): 367-71

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

CPAP administration Nasal interfaces Technique for pressure generation

Nasal interfaces

Nasal interfaces

Nasopharyngeal ET tube

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.

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

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

Levels of CPAP

Failure of CPAP PaO2 <50 mm Hg in 100% oxygen at pressure 10-12 cm H2O If nasal CPAP fails, ET CPAP can be tried IPPV if PaO2 is <50 mm Hg or pH <7.25

Effective CPAP Low cost technology Simple

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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