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  1. 1. CPAP therapy in the Newborn Thrathip Kolatat M.D. Neonatal Intensive Care Unit Department of PediatricsFaculty of Medicine Siriraj Hospital
  2. 2. Continuous Positive Airway Pressure (CPAP)
  3. 3. CPAPl the application of positive airway pressure throughout the respiratory cycle during spontaneous respirationl history l Harrison 1968: described grunting in neonates as naturally producing end- end- expiratory pressure l Gregory et al, 1971: introduced the clinical use of distending pressure in neonates
  4. 4. Physiologic effects of CPAPl pulmonary mechanicsl cardiovascular stabilityl pulmonary vascular resistance
  5. 5. Pulmonary effectsl decrease respiratory rate, tidal volume and minute volumel regularization of respirationl increase FRC and thoracic gas volumel decrease lung compliance and dynamic compliancel decrease total airway resistancel protective effect on surfactant
  6. 6. Effect of CPAP on FRC in the infants with RDS 20 15 10 FRC (ml/kg) Control 5 +4 torr 0 2 3 4 Age (days)
  7. 7. Effect of different CPAP levels on PaO2 300 200 Pa o(torr) 2 100 0 4 8 12 16 20 CPAP (torr)
  8. 8. Cardiovascular effectsl compromise venous return results in diminished cardiac output l depend on lung compliance l sign and symptom: tachycardia, metabolic acidosis, hypotension, decreased dynamic compliance, carbon dioxide retentionl decrease peripheral and regional blood flowl decrease oxygen available to tissuel increase extra-pulmonary shunting secondary to an increase in pulmonary vascular resistance
  9. 9. Effects of CPAPl Renal function l decrease renal blood flow l decrease urine output and urinary sodium excretion l increase antidiuretic hormone and aldosteronel Gastrointestinal function l decrease gastrointestinal blood flow l abdominal distention (CPAP belly syndrome)l Intracranial pressure (head box CPAP) l increase intracranial pressure l intracranial bleeding
  10. 10. Pressure volume curveis divided into 3 regions l region A: low lung Turbulent High-Velocity Laminar Low-Velocity Flow Region Flow Region volume, low compliance and high resistance. The .08 10,000 Airway Cross-Section in cm2 Normal Resistance (cm H2O/L(ml) s) P/V slope is low Newborn 1000 Volume per .06 Lung l region B: optimal lung .04 100 volume and increases .02 10 HMD Lung lung compliance 2 l region C: high lung 0 5 10 15 20 volume, low lung Airway Generation2O) Pressure (cmH compliance Pressure- volume curve
  11. 11. Type ofCPAP
  12. 12. Clinical applications of CDP or CPAP l respiratory distress syndrome l meconium aspiration syndrome l apnea of prematurity l postoperative thoracotomy l patent ductus arteriosus l postoperative celosomia l weaning patients from primary lung disease l differentiation of primary lung disease from primary cardiac disease l as adjunct to intermittent positive ventilation l sleep apnea l bronchomalacia
  13. 13. Clinical applications of CPAP Low (2-3 cm H2O) Use Side effectsl maintenance of lung volume in l may be too low to maintainVLBW infants adequate lung volume orl during weaning adequate oxygenationl during hyperventilation inPPHN Medium (4-7 cm H2O) Use Side effectsl increasing lung volume in If lungs have normal compliancesurfactant deficiency l over distentionl stabilizing areas of atelectasis l impede venous returnl stabilizing obstructed airway l air leak
  14. 14. High (8-10 cm H2O) Use Side effectsl preventing alveolar collapse l air leakwith poor CL and poor lung l decreased CL if over distendedvolume l may impede venous returnl improving distribution of l may increase PVRventilation l CO2 retention Ultrahigh (11-15 cm H2O) Use Side effectsl tracheal or bronchial collapse l air leakl markedly decreased CL or l decreased CL if over distendedsevere obstruction l may impede venous returnl preventing white-out or re- l may increase PVRestablishing lung volume during l CO2 retentionECHO
  15. 15. Tracheomalacia
  16. 16. Optimal CPAP level Disease Physiology Optimal CPAP levelAcute RDS l significant A-a gradient l PaO2 l rapid change compliance l oxygen consumption l oxygen deliverySmall premature l small A-a gradient l lung complianceinfant weaning off l weak respiratory musclesCPAP l increased chest wall complianceBPD on 60% l decreased compliance l pulmonary mechanics:oxygen l increased resistance resistance, compliance4-day-old RDS l congestive heart failure l balance betweenand PDA and pulmonary edema cardiac output and pulmonary blood flow
  17. 17. Clinical use of CPAPl clinical indications l follow up and l sign of atelectasis on weaning chest film l follow-up PaO2 within l chest wall retraction 15-20 min. l require FiO2>0.5 l weaning l display rapidly l after oxygenation progressive lung disease was improvedl initial pressure setting l extubation from l nasal or nasopharyngeal: CPAP 3-4 cm H2O 6 cm H2O l endotracheal: 4 cm H2O
  18. 18. Nursing care of CPAPl method l nursing care l nasal l continuous care (oxygen, l nasopharyngeal pressure) l endotracheal tube l care of airway l face mask l prevent obstructionl components l prevent irritation of l oxygen nares l temperature and l skin care humidity l abdominal distention l pressure l NPO
  19. 19. Indication of CPAPAtelectatic disordersl PaO2 below 50-60 mm Hg in FiO2>0.6l recurrent apneaInitial setupl CPAP 6 cm H2Ol increase 2-cm. increments q 15 min. to a max. of 10 cm H2O or 12 cm H2Ol increase FiO2 0.05-0.10 if PaO2<50 mm H2O
  20. 20. Respiratory distress syndrome l improve survival rate, especially larger infants l modify course of the disease l lower max.FiO2 required, reduce total amount of time under O2 and the need for mechanical ventilation
  21. 21. Early CPAP in RDSl was proved to be more beneficial in the atelectatic diseasel lower peak pressure required in infants treated with CPAPl enhance surfactant conservationl reduce the need for IMV by 20%, except infants with birth weight <1500 g.l improve mortality and decrease the incidence of BPDl prevent need for prolong intubation which reduce the incidence of acquired subglottic stenosis
  22. 22. Failure of CPAP therapy in RDSl very low birth weight infantl late application of CPAPl severity of RDSl associated disease e.g. sepsis, hypotensionl infants with severe degree of extra- pulmonary shunt (Fox and coworkers, 1977)
  23. 23. CPAP in apnea of prematurityl the application of low-level CPAP decrease the incidence of apnea of prematurity (compared to other forms of stimulation) l improve oxygenation l stimulation or inhibition of pulmonary reflexes l alveolar stabilization l mechanical splinting of airway; reduce supraglottic resistance in both inspiration and expirationl some investigators recommended the early use of CPAP as a preventive measure of apnea of prematurity
  24. 24. CPAP in an infant with MASl pathology of meconium aspiration l atelectasis l large airway obstruction l V/Q abnormalitiesl application of low-to moderate level CPAP l resolution of atelectasis l stabilization of terminal airwayl incidence of pneumothorax: not increasedl precautions in case with PPHN
  25. 25. Adverse effects of CPAPl pulmonary air leaks l type of CPAP l lung compliance l gestational agel gastric dilation and rupturel hypotensionl increase pulmonary vascular resistancel chronic lung disease ?
  26. 26. Complication of face mask CPAP