Bubble CPAP vs. High Flow Nasal Cannula Gil Urquidez, RRT-NPS Supervisor, Respiratory Care Services Santa Clara Valley Medical Center

Optimize Initial Respiratory Support Goal: To establish and maintain the VLBW infant’s respiratory efforts and functional residual capacity without injuring the lung (Vent Induced Lung Injury) from excessive use of positive pressure ventilation. 2

Continuous Positive Airway Pressure What is CPAP ? Continuous Positive Airway Pressure Technique of applying a continuous distending pressure to the lungs in a spontaneous breathing infant. Usually< 10 cm of water pressure 5-10L humidified flow of blended air

How does it Work ? Distends the airway and alveoli Maintains lung volume in expiration/FRC Makes breathing easier Improves gas exchange

Philosophy of use Patience Permissive Hypercapnea Non invasive application

CPAP Beneficial effects immediately following Resuscitation Benefits Decreased requirements for Intubation Decreased requirement for high levels of inspired Oxygen Decreased Mechanical Ventilation Length of Stay Decreased need of Postnatal steroids Compared to Historical controls P.Jegatheesan J of Perinatology 2006 26, 189 - 196

CPQCC Recommendation… Tool-Kit Best Practice #7 Optimize Initial Respiratory Support Early use of CPAP (within 60 seconds of life) Avoid Intubation (if possible) Avoid prophylactic use of Surfactant in the DR

What Causes Chronic Lung Disease (CLD)?

Summary of Current Causes of CLD/BPD in VLBW EFFECT Pressure Volume Repeated popping open Less alveoli Not enough resources to grow Scarring and destruction Barotrauma Volutrauma Atelectotrauma Developmentally Impaired Alveolarization and Vascularization Poor Nutrition Recurrent infections

Why Did VMC Switch to Bubble CPAP Therapy?

Bubble Nasal CPAP Cost Effectiveness Less Invasive Than A Other Interfaces To Improve Overall Outcomes Columbia Medical Center’s Experience CLD rates are the lowest in the country Bubble CPAP is SOLE form of Nasal CPAP.

Positive Outcomes Associated With The Change In Practice

Benefits Associated With Change In Practice

Improved Outcomes Associated With Change In Practice

VLBW survival WITHOUT significant IVH SCVMC NICU

How do we create our own Bubble CPAP System? How do we do it? What equipment do we use? Where do we get it?

Creating our Setup Where do we start?

What hat to use? Where do we get them? Creating our Setup What hat to use? Where do we get them?

Creating our Setup Preparing for the cannula

Creating our Setup Securing the cannula to the patient

Creating our Setup Chin straps

Creating our Setup Water Bottles

Creating our Setup Original Setup

How can we improve it!

Creating our Setup Other options

Creating our Setup Other Options

Creating our Setup Other Options

Creating our Setup Previous System

Current Set Up

New Circuit & Bubble Chamber

Multiple Sizes for Prongs/Mask

High Flow Nasal Cannula

Definition High Flow Nasal Cannula is defined as heated humidified gas delivered at flows greater than 1lpm. VMC defines High Flow Nasal Cannula as heated humidified gas delivered at 2lpm.

High Flow Nasal Cannula Set-Up

Cochrane Collaborative Review of High Flow Nasal Cannula 2011 Issue 5 There is insufficient evidence to establish the safety or efficacy of HFNC as a form of respiratory support in the preterm infant When used following extubation there may be a higher reintubation rate compared to NCPAP More trials are needed

Early Weaning From NCPAP To HFNC Is Associated With Prolonged Oxygen Use Randomized control trial Clinically stable on < 30 % O2 for 24 hrs randomized to HFNC (2 L) or Stay on CPAP till go straight to room air. NCAPAP N/C 2 L Days on O2 5 14 Resp support days 10.5 18 Hany ES Early Human Development 2011

High Flow Nasal Cannula PRO’s for HFNC Use Ease of use Improved feeding and tolerance Easier nursing/patient handling Decreased nasal septal trauma

High Flow Nasal Cannula CON’s for HFNC use Limited data Unmeasured PEEP No alarms

VMC’s Position on HFNC High Flow Nasal Cannula usage when: Patient fails multiple attempts off Bubble NCPAP Is still needing more than 2lpm flow

Greg Is Not Happy with the Baby’s NCPAP Set Up

What’s wrong with this set up?

The Baby Is Agitated and Desating! What Can We Do To Fix This?

Aaahhh….I feel much better!

I Can See You!!!

Greg’s NOW a Happy Nurse!!!

A Happy Baby is a Happy Nurse And ULTIMATELY a HAPPY RT!!!

MATCH the Definition on the RIGHT with the Therapy on the LEFT Conclusions MATCH the Definition on the RIGHT with the Therapy on the LEFT CPAP is Bubble CPAP is High Flow Nasal Cannula Oxygen is a Drug Good Needs Further Study  Good Use with caution Great Great Needs Further Study Use with Caution

Thank Yous!!! Craig Ivie, Director, Respiratory Care Services Dr. Balaji Govindaswami, Director, NICU All Associate Attendings All NICU Staff My Respiratory Care Staff