1. 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.

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 Jun 17;284(24):

3. 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.

4. 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

5. Effective
CPAP
Low cost technology
Simple

6. 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)

7. 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)].

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
FiO2 above 0.3 with clinical distress
FiO2 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 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

14. 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.

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. 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.

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

24. 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.

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 Indigenous Infant Bubble CPAP System
Fisher and paykel 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
CPAP
Low cost technology
Simple

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

31. Thank You