seminar on CPAP care

1. Presenter:
 Dr. Sharmin Afroze ,Resident (Phase –B), Neonatology
 Dr. Ismat Jahan,Resident (Phase-A), Paediatrics
Welcome To Seminar

2. Case Scenario
 A 30 weeker female baby weighing 1160 gm, born by LUCS
and cried immediately after birth. But soon she developed
respiratory distress in the form of grunting, severe chest
indrawing and cyanosis in room air. Baby was admitted in
NICU and O2 was started along with other supportive
measures. Gradually her respiratory distress was increasing,
saturation was not maintaining with 5 L/min O2 through
head box. There was increasing tachypnea and work of
breathing. Bilateral air entry was poor.
What respiratory support could be given to
patient at that time ?

3. Continuous Positive Airway Pressure
(CPAP) in Newborn

4. Presentation Outline
 Introduction to CPAP
 Definition of CPAP
 Background of CPAP
 Indications & contraindications
 How does it work?
 Physiological importance of CPAP pressure
 Different types of CPAP pressure generators and delivery system
 Guideline for CPAP therapy
 Initiation & weaning from CPAP
 Monitoring while on CPAP & prevention of complications
 Practical issues and recent advancements of CPAP

5.  Continuous positive airway pressure (CPAP) is a simple, inexpensive
and gentle mode of respiratory support in preterm very low birth
weight (VLBW) infants.
 Continuous positive airway pressure (CPAP), often thought to be the
‘missing link’ between supplemental oxygen and mechanical
ventilation.
 It is gaining immense popularity in neonatal intensive care units.
Being technically simple, inexpensive and effective, it has become
the primary mode of respiratory support in preterm very low birth
weight (VLBW) infants.
Introduction

7. What is CPAP?
Continuous positive airway pressure (CPAP) is a form of
noninvasive ventilation where a positive pressure is
applied to the airway of a spontaneously breathing
infant through out the respiratory cycle, thereby
preventing the collapse of alveoli & terminal airways
during expiration.

8. Background History of CPAP
 In the early 1970s, Gregory et al. demonstrated that providing CPAP
using an anesthesia bag improved oxygenation in preterm infants
with respiratory distress syndrome.
 Subsequently, Dr. Jen-Tien Wung at Children’s Hospital of New York,
Columbia University developed the Bubble CPAP system using short
nasal prongs.
 In 1987 Avery et al. reported large differences in the risk-adjusted
incidence of Bronchopulmonary dysplasia in a comparison of 12
academic neonatal intensive care units in the United States.

9. Indication of CPAP
 Initial stabilization in the delivery room for spontaneously
breathing extremely premature infants(25-28 wks’ gestation)
 Recently delivered premature infant with minimal respiratory
distress and supplemental oxygen requirement to prevent
atelectasis
 Respiratory distress and requirement of FiO2 above 0.3-0.4
head box
 In InSurE approach
Renni & Roberton’s Textbook of Neonatology, 5th edition

11. Contraindications to CPAP
1. Progressive respiratory failure with PCO2>60 mmHg and/or inabitity to
maintain oxygenation (PO2<50 mmHg)
2. Certain congenital malformations of the airway
- Choanal atresia
- Cleft palate
-Tracheo-esophageal fistula
-Congenital diaphragmatic hernia
3. Conditions with imminant ventilatory support
- Severe cardio-respiratory compromise
-Poor respiratory drive

12. How Does It Work?
CPAP predominantly helps by preventing collapse of the alveoli
with marginal stability
Recruitment of more alveoli
Increase the functional residual capacity (FRC)

14. CPAP And Patient Airway Pressure

15. Physiological Importance of CPAP
Pressure
 Low (2-3 cm H2O)
 Medium (4-7 cm H2O)
Use Side Effect
•Maintenance of lung
volume in VLBW infants
•May be too low to maintain
adequate lung volume or
adequate oxygenation
•During weaning
•During hyperventilation
Use Side Effect
• Increasing lung volume in
surfactant deficiency
If lungs have normal
compliance-
• Overdistension
• Impedes venous return
• Airleak
• Stabilizes areas of
atelectasis
• Stabilizes obstructed airway

16.  High (8-10 cm H2O)
Use Side Effects
• Preventing alveolar
collapse with poor
compliance & poor lung
volume
• Air leak
• Improving distribution of
ventilation
• Decreased compliance if over
distended
• May impede venous return
• May increase PVR
• CO2 retention

17. Devices used for pressure generation

18. Different Types of CPAP Pressure
Generators
Bubble CPAP Ventilator CPAP Flow Driver CPAP

19. Nasal prongs
Nasal cannulae
Face masks
Nasopharyngeal tubes
Head box with nasal seal
Endotracheal tubes
Different Techniques of Delivering CPAP

20. • Hudson
• Inca
• Fisher & Paykel
• Argyle
Types of prongs

21. Bubble continuous positive airway
pressure system
– Simple and inexpensive
– Leakage of circuit can be easily identified
– Adequacy of flow can be seen and heard

22. Seminar on CPAP in Newborn

23. Guidelines for CPAP therapy
How to initiate CPAP?
How to Wean from CPAP?
How to take care of these babies?
Monitoring baby while in CPAP
Complications of CPAP therapy & how to manage?
Practical issues regarding CPAP
Recent advancements

24. When to initiate CPAP?
Prophylactic CPAP:
Extending this logic, some have advocated use of
prophylactic CPAP (before the onset of respiratory distress)
in preterm VLBW infants as majority of them would
eventually develop respiratory distress.
Early CPAP:
All preterm infants (<35 weeks’) with any sign of
respiratory distress (tachypnea/chest in-drawing/grunting)
should be started immediately on CPAP.
Guidelines for CPAP Therapy

25.  It is important to note that CPAP helps mainly by preventing
the alveolar collapse in infants with surfactant deficiency.
 Once atelectasis and collapse have occurred, CPAP might
not help much.

26. Assess respiratory status by scoring systems
 Pressure(PEEP): Start at 5 cm H2O
 FiO2: 0.5
 Flow: 5 L/min
How to Initiate CPAP?

27. Pressure(PEEP):Increase in steps of 1-2cm H2O to reach a
maximum of 8 cm H2O
FIO2:Increase in steps of 0.05 (if oxygenation is still
compromised) up to a maximum of 0.8
Flow: Usually constant
How to proceed?

28. When to wean ?
When baby fulfils the criteria of having “Optimum CPAP”
attempts should be taken to wean from CPAP
How to wean ?
Reduce FiO2 in steps of 0.05 to 0.3, then decrease pressure in
steps of 1-2cm H2O until 3-4 cm H2O
*****Infants clinical condition will guide the speed of weaning
Weaning from CPAP

29.  The infant’s nose and mouth should be suctioned thoroughly
prior to, and after removal of CPAP
 The infant is carefully monitored after removal of the CPAP
for evidence of tachypnea, retractions, or increased apnea and
bradycardia
 The infant is suctioned every 6 hours for the first 24 hours
after the removal of CPAP
Procedures for removal of CPAP

30. Worsening respiratory distress (as indicated by
Silverman or Downe’s scoring)
Hypercarbia(PCO2 >60mmHg) and/Hypoxemia (PO2
<50mmHg) ,despite FiO2 of 0.6 and Ph <7.25
Failure of CPAP

31.  If the infant develops frequent apnea and bradycardia
episodes, tachypnea or retractions, then CPAP is
reintroduced
Indications for reintroducing CPAP

32.  The nasal prongs can be secured by putting on an
appropriate sized hat
 Nasal prongs must be properly placed to prevent air leak
 Gentle nasal suctioning is important to maintain clear
airways.
 Frequent decompression of the infant’s stomach with an
oro-gastric tube is necessary
Care of Infant on CPAP

33.  Regular but gentle nasal suction to clear the mucus 4
hourly or as and when required
 Clean the nasal cannula and check its patency once per
shift
 Change the infant’s position regularly every 2-4 hours and
check the skin condition frequently for redness and sores.
Care of Infant on CPAP

34. 1. Continuous monitoring of respiratory rate,
heart rate, SpO2, perfusion status
2. Chest X-ray to check lung expansion
3. Serial monitoring of
 respiratory distress by using Downe’s or
Silverman score
 Arterial blood gases (ABGs)
 Perfusion - CFT, BP, peripheral pulses, urine
output
 Abdominal girth
The target saturation and blood gas during
CPAP therapy are: SpO2 - 90-93%; PaO2 –
50 to 70 mmHg; PaCO2 – 45 to 50 mmHg)
MONITORING WHILE ON CPAP

35. • Respiratory status (RR,
work of breathing)
• Oxygen saturation
• Cardiovascular status (HR,
BP, perfusion)
• GI status (abdominal
distention, bowel sounds)
• Neurological state (tone,
activity, responsiveness)
• Thermoregulation (temp)
Monitoring the Infant’s Condition

36. • Suction the mouth, nose
and pharynx 3 – 4 hrly
• For symptomatic infants
more frequent suctioning
may be needed
Maintaining Airway While on CPAP

37. • Moisten the nares with
normal saline or sterile
water to lubricate the
catheter and loosen dry
secretions
Maintaining Airway While on CPAP

38. • Maintain adequate
humidification of the circuit
to prevent drying of
secretions
• Adjust settings to maintain
gas humidification at or close
to 100%
• Set the humidifier temp to
36.5-37.5o C
Maintaining Airway : Humidification

39. Complications Associated With
CPAP

40. Nasal irritation, septal erosion or necrosis
-Keep prongs away from the septum
Nasal obstruction
- Remove secretions and check for proper positioning of
the prongs
Feeding intolerance
Gastric distension
CPAP belly syndrome
Pneumothorax

41. • Septal injury is
preventable
• Damage to the septum
arises when poorly fitted
or mobile prongs cause
pressure and/or friction
Preventing Complications: Nasal Septal
Injury

42. Journal of School & Nursing, Brazil
Prevalence of nasal septum injury in premature infants using nasal prongs
Nayara Francisca et al.
The aim of this study was to investigate the prevalence and factors associated
with nasal septum injury in preterm infants in the use of noninvasive ventilation.
A cross-sectional study was done with data collection between March and July
2012.
Results: The prevalence of nasal lesions was 68.1%, associated with low birth
weight and duration of treatment. The prevalence of nasal injury in this
population is high and associated with low birth weight and length of stay in
noninvasive ventilation.
Conclusion: Birth weight and length of use of NIV with short binasal prongs were
directly associated with the appearance of nasal septum injury. The results of
this study reinforce the fact that nursing care is one of the pillars of prevention
of nasal lesions in preterm infants in the NIV who use nasal prongs. The care in
handling, maintenance and sitting of equipment that make up the circuit should
be prioritized. Studies aimed at evaluating such care must be carried out with

43. To prevent damage to the
nasal septum:
• Maintain distance of 2-3 mm
between bridge of prongs and
septum
• Avoid twisting of prongs
• Do not use adhesive barriers
(Duoderm) on the septum
• Evaluate the nasal septum
• Use correct prong size
• Secure prongs in place correctly

44. • CPAP is not a
contraindication to enteral
feeding
• Infants may experience
mild abdominal distention
during bCPAP from
swallowing air
Preventing Complications: Gastric
Distention

45. To prevent gastric
distention:
• Assess the infant’s abdomen
regularly
• Pass an oro-gastric tube to
aspirate excess air before feeds
• An 5 Fr oro-gastric tube should
be left indwelling to allow for
continuous air removal
CPAP belly

46. • Pneumothorax, if occurs, is
likely to occur during the
acute phase of respiratory
distress.
• Pneumothorax is usually
not due to CPAP and is not
a contraindication to
continuing CPAP
Preventing Complications:
Pneumothorax

47. ASAIO J. 2002 Sep-Oct;48(5):476-9
Pneumothorax and nasal continuous positive airway pressure ventilation in
premature neonates: a note of caution.
Makhoul IR, Smolkin T, Sujov P
The nasal continuous positive airway pressure (NCPAP) system has recently gained
wide use in premature infants. The purpose of this study was to verify whether the
use of NCPAP, namely Aladdin-1, increases the risk for pneumothorax. The study
included premature infants with respiratory distress who necessitated one or more
of the following modes: oxygen via head box, NCPAP, synchronized intermittent
mandatory ventilation (SIMV), or high frequency oscillatory ventilation (HFOV). For
every patient, we recorded the modes of respiratory support, duration of use, and
the occurrence of pneumothorax
Among 163 sick premature neonates, pneumothorax developed in 0.17, 1.77, 0.3,
and 6 cases per 100 days of oxygen via head box, NCPAP, SIMV, and HFOV,
respectively. Pneumothorax developed more often during NCPAP than with SIMV.

48. Pediatr Med Chir. 2003 Sep-Oct;25(5):345-8
[Pneumothorax during nasal-CPAP: a predictable complication?]
[Article in Italian]
Migliori C, Campana A, Cattarelli D, Pontiggia F, Chirico G
OBJECTIVE:
Pneumothorax (PNX) is a relatively common complication of nasal-CPAP (N-CPAP). Aim of
the study was to identify prognostic factors of its onset.
RESULTS:
The patients with PNX needed a FiO2 28% higher than the initial value after 12 hours of
treatment, and 46% higher at 24 hours (p = 0,017). At diagnosis, FiO2 was 53,5% higher
than the initial value (p = 0,005).
CONCLUSION:
A 40% increase of FiO2, during the first 24 hours of N-CPAP may represent an useful
marker to identify the infants at high risk of developing a pneumothorax.

49. Practical Issues of CPAP

50. • The infant on CPAP may be
positioned supine, prone, or
side lying
• When positioning supine or
side lying support airway
alignment with a neck roll
Positioning While on CPAP

51. • When positioning prone
place a chest pad under
the infant.
• Make a firm pad using
linen which is the same
size as the infant’s chest

53. Phototherapy While on CPAP

54.  Pass an orogastric tube
 Keep the proximal end of tube open
 If the infant is being fed while on CPAP, close the
tube for half an hour after giving feeds and
 Keep it open for the next 90 minutes (if fed
2hourly)
Feeding While on CPAP

55. Kangaroo Mother Care (KMC) While
on CPAP

56.  Arch Dis Child 2012;97:A512 doi:10
 Reduced Duration of CPAP in Preterm Babies Receiving Kangaroo Care within an
Hour of Birth - Randomized Trial
 SM Nimbalkar, R Tandon
 Prospective randomized controlled trial in a total of 16 preterm neonates with
respiratory distress syndrome who were assigned to CPAP (Fischer Paykel
Bubble CPAP generator with short bi-nasal prongs) with or without KMC within 1
hour of starting CPAP. Primary outcome was requirement of oxygen and
mechanical ventilation. Secondary outcome was early initiation of feed, apnoeic
episodes and number of days for achieving maximum feed.
 13 babies were randomised into intervention group and 12 in control group. The
mean weight was 1.51kg (SD=0.47) and gestational age range of 26–32 weeks.
Babies took 34.08 hrs to wean off in CPAP with KMC as compared to 38.67 hrs in
those who received only CPAP.
 KMC is feasible in babies on CPAP irrespective of weight and prematurity. It
reduced the number of hours on CPAP and reduced intolerance of feeds.

57. Recent Advancements of CPAP

58.  Journal of Perinatology (2003) 23, 195–199
 Early Bubble CPAP and Outcomes in ELBW Preterm Infants
 Vivek Narendran et al.
 OBJECTIVE: To test whether the introduction of early bubble continuous positive
airway pressure (CPAP) results in improved respiratory outcomes in extremely
low birth-weight infants. Study was done between 401 and 1000g born in a level
3 neonatal intensive care units (NICU) between July 2000 and October 2001
(period 2) were compared using historical controls (period 1)
 RESULTS: Delivery room intubations, days on mechanical ventilation and use of
postnatal steroids decreased (p<0.001) in period 2, while mean days on CPAP,
number of babies on CPAP at 24 hours (p<0.001) and mean weight at 36 weeks
corrected gestation also increased (p<0.05) after introduction of early bubble
CPAP.
 CONCLUSIONS: Early bubble CPAP reduced delivery room intubations, days on
mechanical ventilation, postnatal steroid use and was associated with increased
postnatal weight gain with no increased complications.

59.  Iran J Pediatr. 2011 Jun; 21(2): 151–158
 Bubble–CPAP vs. Ventilatory–CPAP in Preterm Infants with
Respiratory Distress
 Bahareh et al.
 This prospective clinical trial was performed on 50 preterm
neonates weighing 1000-2000 gm of respiratory distress between
June 2009 and May 2010
 B-CPAP was effective in the treatment of neonates who were
suffering from respiratory distress and reduced the duration of
hospital stay. In addition to mentioned benefits, its low cost may be
the reason to use B-CPAP broadly compared with V-CPAP.

60. • Correctly set up and maintain low resistance delivery circuit
• Securely attach interface
• Assure minimal pressure leaks
• Maintain optimal airway
• Prevent nasal septal injury
• Encourage committed and skilled caregivers
Key Points to Remember on CPAP