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

2. 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

3. 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

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

5. Philosophy of use Patience Permissive Hypercapnea
Non invasive application

6. 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 ,

7. 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

8. What Causes Chronic Lung Disease (CLD)?

9. 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

10. Why Did VMC Switch to Bubble CPAP Therapy?

11. 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.

12. Positive Outcomes Associated With The Change In Practice

13. Benefits Associated With Change In Practice

14. Improved Outcomes Associated With Change In Practice

15. VLBW survival WITHOUT significant IVH
SCVMC NICU

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

18. Creating our Setup
Where do we start?

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

20. Creating our Setup
Preparing for the cannula

21. Creating our Setup
Securing the cannula to the patient

22. Creating our Setup
Chin straps

23. Creating our Setup
Water Bottles

24. Creating our Setup
Original Setup

26. How can we improve it!

27. Creating our Setup
Other options

28. Creating our Setup
Other Options

29. Creating our Setup
Other Options

30. Creating our Setup
Previous System

31. Current Set Up

32. New Circuit & Bubble Chamber

33. Multiple Sizes for Prongs/Mask

34. High Flow Nasal Cannula

35. 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.

36. High Flow Nasal Cannula Set-Up

37. 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

38. 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

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

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

41. 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

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

43. What’s wrong with this set up?

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

45. Aaahhh….I feel much better!

46. I Can See You!!!

47. Greg’s NOW a Happy Nurse!!!

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

49. 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

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