seminar on CPAP care green

1.  Guidelines for CPAP therapy
 How to initiate CPAP?
 Essentials of 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
 Procedures of removal of CPAP
 Take home message

2. When to initiate CPAP?
Early CPAP:
 All preterm infants (<35 weeks’ gestation) with any sign
of respiratory distress (tachypnea / chest
in-drawing / grunting) should be started immediately on
CPAP.
 CPAP helps mainly by preventing the alveolar collapse
in infants with surfactant deficiency.
 Once atelectasis and collapse have occurred, CPAP
might not help much.
Guidelines for CPAP Therapy

3. Prophylactic CPAP:
Extending the logic behind early CPAP, some have
advocated the use of prophylactic CPAP (before the onset of
respiratory distress) in preterm VLBW infants as majority of
them would eventually develop respiratory distress.

4. Cochrane Database Syst Rev. 2016 Jun 14;(6):CD001243.
Prophylactic nasal continuous positive airway pressure for
preventing morbidity and mortality in very preterm infants.
Subramaniam P, Ho JJ, Davis.
BACKGROUND: Cohort studies have suggested that nasal
continuous positive airways pressure (CPAP) starting in the
immediate postnatal period before the onset of respiratory disease
(prophylactic CPAP) may be beneficial in reducing the need for
intubation and intermittent positive pressure ventilation (IPPV) and in
preventing bronchopulmonary dysplasia (BPD) in preterm or low birth
weight infants.
Conclusion:
when compared to mechanical ventilation prophylactic nasal CPAP in
very preterm infants reduces the need for mechanical ventilation and
surfactant and also reduces the incidence of BPD and death or BPD.

5. Essentials of CPAP
 Preparing the circuit, the bubble chamber and the machine
 Fixing the cap
 Securing the nasal prongs or nasal mask
 Connecting the circuit
 Insertion of orogastric tube
 Setting of pressure, FiO2, and flow

6. Application of CPAP therapy in the three common neonatal conditions
Indications
RDS Apnea of prematurity Post extubation
How to initiate CPAP?
Pressure
Fio2
• 6-7 cm of H2O
• 0.5 (titrate based on
SPO2)
• 4-5 cm of H2O
• 0.21- 0.4
• 4-5 cm of H2O
• 0.05 – 0.1above the
pre-extubation FiO2
What to do if there is no
improvement?
Pressure
FIO2
• Increase in steps of
1-2 cm H2O to reach
a maximum of 7-8 cm
H2O
• Increase in steps of
0.05 up to a
maximum of 0.8
• Increase up to 5 cm
H2O.
• FiO2 increase does
not help much
• Increase in steps of
1-2 cm H2O to reach
a maximum of 7-8 cm
H2O
• Increase in steps of
0.05 up to a
maximum of 0.8
References : Management Protocol of newborn doctor’s Handbook BSMMU
AIIMS Protocols in neonatology

7. Weaning from CPAP
When to wean ?
When baby fulfills 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
Infant’s clinical condition will guide the speed of weaning

8. J Perinatol.2017 Jun;37(6):662-667
Sudden versus gradual pressure wean from Nasal CPAP in
preterm infants: a randomized controlled trial.
Amatya S, Macomber M, Bhutada A, Rastogi D, Rastogi S
OBJECTIVE: In preterm infants, nasal continuous positive airway
pressure (NCPAP) is widely used for treatment of respiratory distress
syndrome. However, the strategies for successfully weaning infants
off NCPAP are still not well defined and there remains considerable
variation between the methods. The objective of this study is to
determine whether gradual weaning of NCPAP pressure is more
successful than sudden weaning off NCPAP to room air.
Conclusions:
Gradual weaning method was more successful as compared to
sudden weaning method in the initial trial off NCPAP. There was no
difference in the PMA, weight at the time of successful wean.

9. World J Pediatr.2015 Feb;11(1):7-13.
Weaning of nasal CPAP in preterm infants: who, when and how? a
systematic review of the literature.
Amatya S, Rastogi D, Bhutada A, Rastogi S.
BACKGROUND: There is increased use of early nasal continuous positive airway
pressure (NCPAP) to manage respiratory distress in preterm infants but optimal
methods and factors associated with successful wean are not well defined. A
systematic review was performed to define the corrected gestational age (CGA),
weight to wean NCPAP and the methods associated with successful weaning of the
NCPAP among preterm infants, along with factors affecting it.
RESULTS :Seven studies met the search criteria. The successful wean was at 32 to
33 weeks CGA and at 1600 g. Three different methods were used for weaning were
sudden, gradual pressure wean and gradual graded time off wean. Criteria for
readiness, success and failure to wean were defined. Factors affecting successful
weaning were intubation, anemia, infection and gastro-esophageal reflux.
CONCLUSIONS :The successful wean was at 32 to 33 weeks CGA and 1600 g.
Criteria for readiness, success and failure to wean are well defined. Sudden weaning
may be associated with a shorter weaning time. Future trials are needed comparing
weaning methods using defined criteria for readiness and success of NCPAP wean
and stratify the results by gestational age and birth weight.

10.  The nasal prongs/ nasal mask can be secured by putting on
an appropriate sized hat
 Nasal prongs/ nasal mask 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

11.  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

12. 1. Vitals: temperature, respiratory rate, heart rate, SpO2
2. Assessment of circulation: CRT, BP, urine output
3. Scoring of respiratory distress: Silverman score or with
Downe’s score
4. Abdominal distension monitoring: bowel sounds and astric
aspirates to prevent CPAP belly
5. Neurological assessment:Tone,activity, and responsiveness
6. Chest X-ray to check lung expansion
7. Blood gas: It is done once or twice a day during the acute
stage and later when clinically warranted.
MONITORING WHILE ON CPAP

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

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

15. • 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

16. Complications associated with CPAP
 Nasal irritation, damage to the septal mucosa, or skin damage and
necrosis from the fixing devices.
 Nasal obstruction
- Remove secretions and check for proper positioning of
the prongs
 Infection
 Gastric distension
 CPAP belly syndrome
 IVH
 Pneumothorax
 Hypoperfusion

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

18. Trauma due to Nasal Mask

19. Indian Pediatr. 2010 Mar;47(3):265-7.
Effect of silicon gel sheeting in nasal injury associated with nasal
CPAP in preterm infants.
Günlemez A, Isken T, Gökalp AS, Türker G, Arisoy EA
Abstract: We conducted this study to investigate the efficacy of
the silicon gel application on the nares in prevention of nasal injury in
preterm infantsventilated with nasal continuous positive airway
pressure (NCPAP). Patients (n=179) were randomized into two
groups: Group 1 (n=87) had no silicon gel applied to nares, and in
Group 2 (n=92), the silicon gel sheeting was used on the surface of
nares during ventilation with NCPAP. Nasal injury developed in 13
(14.9%) neonates in Group 1 and 4 (4.3%) newborns in Group 2
(OR:3.43; 95% CI: 1.1-10.1; P<0.05). The incidence of columella
necrosis was also significantly higher in the Group 1 (OR: 6.34; 95%
CI: 0.78-51.6; P<0.05).
Conclusion: The silicon gel application may reduce the incidence
and the severity of nasal injury in preterm infants on nasal CPAP.

20. Department of Neonatology, BSMMU Shahbagh, Dhaka, Bangladesh
October-2017
Comparison of Nasal Mask Versus Nasal Prongs for Delivering Nasal
Continuous Positive Airway Pressure in Preterm Infants with
Respiratory Distress Syndrome
Objective of the study: To compare the efficacy of nasal mask vs nasal prongs in
delivering nasal continuous positive airway pressure in preterm infants with
respiratory distress syndrome.
Results: NCPAP failure within 72 hours of initiation of respiratory support in
preterms in the mask group when compared with the prongs group was statistically
not significant (13% vs 22%, P=0.434). Incidence of stage 2 nasal trauma (9% vs
36%, P=0.031) were significantly lower in mask group. Duration of CPAP (4.38±2.78
vs 3.75±2.04days), pneumothorax (4.5% vs 13%), PDA (13% vs 9%), Duration of
hospital stay (16.6±7.8 vs 13.5±8days), Early onset sepsis (4.5% vs 9%), LOS (68%
vs 40%), mortality (7% vs 11%) between the two groups was not significant.
Conclusion: NCPAP with mask interface is equally effective as NCPAP with prongs
interface. Incidence of stage II nasal trauma was significantly lower in mask group
than in the prongs group.

21. Eur J Pediatr. 2017 Mar;176(3):379-386.
Nasal masks or binasal prongs for delivering continuous
positive airway pressure in preterm neonates-a randomised
trial.
Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul VK, Deorari AK
The objective of this study was to compare the efficacy and safety of
continuous positive airway pressure (CPAP) delivered using nasal
masks with binasal prongs. We randomly allocated 72 neonates
between 26 and 32 weeks gestation to receive bubble CPAP by
either nasal mask (n = 37) or short binasal prongs
(n = 35). Incidence of severe nasal trauma was lower with the use of
nasal masks (0 vs. 31%; p < .001).
CONCLUSIONS:
Nasal masks appear to be as efficacious as binasal prongs in
providing CPAP. Masks are associated with lower risk of severe nasal
trauma.

22. Neonatology 2016;109:258-264
Binasal Prong versus Nasal Mask for Applying CPAP to Preterm
Infants: A Randomized Controlled Trial
Say B. Kanmaz Kutman H.G. Oguz S.S. Oncel M.Y Arayici S. Canpolat F.E. Uras N. Karahan
S.
Objective: We aimed to determine whether NCPAP applied with
binasal prongs compared to that with a nasal mask (NM) reduces the
rate of moderate/severe bronchopulmonary dysplasia (BPD) in
preterm infants.
Conclusions: The NM was successfully used for delivering NCPAP
in preterm infants, and no NCPAP failure was observed within the
first 24 h. These data show that applying NCPAP by NM yielded a
shorter duration of NCPAP and statistically reduced the rates of
moderate and severe BPD.

23. 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

24. AJR Am J Roentgenol. 1992 Jan;158(1):125-7.
Benign gaseous distension of the bowel in premature
infants treated with nasal continuous airway pressure: a study of contributing factors.
Jaile JC, Levin T, Wung JT, Abramson SJ, Ruzal-Shapir C, Berdon WE.
Associated with the increased use of nasal CPAP has been the development of
marked bowel distension (CPAP belly syndrome), which occurs as the infant's
respiratory status improves and the baby becomes more vigorous. To identify
contributing factors, compared 5 premature infants treated with nasal CPAP with
29 premature infants not treated with nasal CPAP. Infants were followed up for
development of distension, defined clinically as bulging flanks, increased abdominal
girth, and visibly dilated intestinal loops. We evaluated birth weight, weight at time
of distension, method of feeding (oral, orogastric tube), and treatment with nasal
CPAP and correlated these factors with radiologic findings. Of the infants who
received nasal CPAP therapy, gaseous bowel distension developed in 83% (10/12)
of infants weighing less than 1000 g, but in only 14% (2/14) of those weighing at least
1000 g. Only 10% (3/29) of infants not treated with nasal CPAP had distension, and
all three weighed less than 1000 g. Presence of sepsis and method of feeding did not
correlate with occurrence of distension. Neither necrotizing enterocolitis
nor bowel obstruction developed in any of the patients with a diagnosis of CPAP belly
syndrome. Our study shows that nasal CPAP, aerophagia, and immaturity
of bowel motility in very small infants were the major contributors to the
development of benign gaseous bowel distension.

25. Am J Perinatol. 2011 Apr;28(4):315-20.
Nasal colonization among premature infants treated
with nasal continuous positive airway pressure.
Aly H, Hammad TA, Ozen M, Sandhu I, Taylor C, Olaode A, Mohamed M, Keiser J.
Abstract: examined the relationship between the use of nasal continuous positive
airway pressure (CPAP) and nasal colonization among low-birth-weight (LBW) infants.
We prospectively cultured the nares of LBW infants on admission and weekly until
hospital discharge. The modality of respiratory support during each culture was
recorded. Bivariate and multivariate analyses were conducted to test the relationship
between CPAP and nasal colonization. Analyses were repeated after
stratifying infants into three birth-weight categories: 1500 to 2499 g, 1000 to 1499 g, and
< 1000 g. In total, 766 nasal cultures were obtained from 167 infants. Nasal colonization
with gram-negative bacilli was increased with the use of CPAP in all birth-
weight categories ( P < 0.05) and with vaginal delivery in infants weighing < 1000 g and
1500 to 2499 g ( P = 0.04 and P = 0.02, respectively). Nasal colonization with any
potential pathogen increased with the use of CPAP in all birth-weight categories ( P <
0.001), with the presence of chorioamnionitis in infants < 1000 g ( P = 0.055) and at
younger gestational age in infants 1000 to 1499 g ( P = 0.0026). Caucasian infants 1500
to 2499 g had less colonization than infants of other races ( P = 0.01). Nasal CPAP is
associated with increased colonization with gram-negative bacilli.

26. Indian J Pediatr. 2012 Feb;79(2):218-23.
Neurodevelopmental outcomes of extremely low birth weight
infants ventilated with continuous positive airway pressure vs.
mechanical ventilation.
Thomas CW, Meinzen-Derr J, Hoath SB, Narendran V.
OBJECTIVE:
To compare continuous positive airway pressure (CPAP) vs. traditional mechanical
ventilation (MV) at 24 h of age as predictors of neurodevelopmental (ND) outcomes
in extremely low birth weight (ELBW) infants at 18-22 months corrected gestational
age (CGA).
RESULTS:
Ventilatory groups were similar in gender, rates of preterm prolonged rupture of
membranes, antepartum hemorrhage, use of antenatal antibiotics, steroids, and
tocolytics. Infants receiving CPAP weighed more, were older, were more likely to be
non-Caucasian and from a singleton pregnancy. Infants receiving CPAP had better
BSID-II scores, and lower rates of BPD and death.
CONCLUSIONS:
After adjusting for acuity differences, ventilatory strategy at 24 h of age
independently predicts long-term neurodevelopmental outcome in ELBW infants.

27. • The infant on CPAP may be
positioned supine, prone, or
side lying ( repositioning for
at least every 3to 6 hours
• When positioning supine or
side lying support airway
alignment with a neck roll
Positioning While on CPAP

28.  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

29.  The baby requires frequent change in posture, oral and nasal
suction and occasionally saline nebulization for effective
removal of secretion should be done prior to, and after
removal of CPAP.
 For the 12 to 24 hours after removal of CPAP, careful
monitoring is required for evidence of tachypnea,
worsening retractions, apneas and bradycardia.
Procedures for removal of CPAP

30.  Worsening respiratory distress as indicated by Silverman or
Downe’s scoring
 Apnea > 3 episodes/hr or 1 episode needing bag mask
ventilation
 ABG:
 PCO2 >60 mm Hg)
 PO2 <50 mm Hg)
 FiO2 ≥ 0.6
 Ph <7.25
Failure of CPAP

31. Causes of CPAP failure
 Delay in initiating CPAP
 Intracranial haemorrhage
 Progressive metabolic acidosis
 Pulmonary edema
 Improper fixation of CPAP device and frequent dislodgement
 Excessive secretions obstructing the airways or nasal
prongs

32. Journal of Tropical Pediatrics, Volume 57, Issue 4, 1 August 2011, Pages
274–279,
Clinical Prediction Score for Nasal CPAP Failure in Pre-term VLBW
Neonates with Early Onset Respiratory Distress
Mrinal S. Pillai Mari J. Sankar Kalaivani Mani Ramesh Agarwal Vinod K. PaulAshok K. Deorari
Abstract:62 pre-term very low birth weight neonates initiated on nasal continuous
positive airway pressure (CPAP) for respiratory distress in the first 24 h of life to devise a
clinical score for predicting its failure. CPAP was administered using short binasal prongs
with conventional ventilators. On multivariate analysis, we found three variables—
gestation <28 weeks [adjusted odds ratio (OR) 6.5; 95% confidence interval (CI) 1.5–
28.3], pre-term premature rupture of membranes [adjusted OR 5.3; CI 1.2–24.5], and
product of CPAP pressure and fraction of inspired oxygen ≥1.28 at initiation to maintain
saturation between 88% and 93% [adjusted OR 3.9; CI 1.0–15.5] to be independently
predictive of failure. A prediction model was devised using weighted scores of these three
variables and lack of exposure to antenatal steroids. The clinical scoring system thus
developed had 75% sensitivity and 70% specificity for prediction of CPAP failure (area
under curve: 0.83; 95% CI 0.71–0.94).
Conclusion: a simple clinical score comprising four variables namely, gestational age
<28 weeks, PPROM, lack of exposure to ANS, and product of CPAP pressure and
FiO2 ≥1.28 would predict failure of nasal CPAP in pre-term VLBW infants with reasonable
accuracy.

33. Pediatrics July 2016, VOLUME 138 / ISSUE 1
Incidence and Outcome of CPAP Failure in Preterm Infants
Peter A. Dargaville, Angela Gerber, Stefan Johansson, Antonio G. De Paoli, C. Omar F.
Kamlin, Francesca Orsini, Peter G. Davis, for the Australian and New Zealand Neonatal
Network
RESULTS: Within the cohort of 19 103 infants, 11 684 were initially managed on
CPAP. Failure of CPAP occurred in 863 (43%) of 1989 infants commencing on
CPAP at 25–28 weeks’ gestation and 2061 (21%) of 9695 at 29–32 weeks. CPAP
failure was associated with a substantially higher rate of pneumothorax, and a
heightened risk of death, bronchopulmonary dysplasia (BPD) and other morbidities
compared with those managed successfully on CPAP. The incidence of death or
BPD was also increased: (25–28 weeks: 39% vs 20%, AOR 2.30, 99% confidence
interval 1.71–3.10; 29–32 weeks: 12% vs 3.1%, AOR 3.62 [2.76–4.74]). The CPAP
failure group had longer durations of respiratory support and hospitalization.
CONCLUSIONS: CPAP failure in preterm infants is associated with increased risk
of mortality and major morbidities, including BPD. Strategies to promote successful
CPAP application should be pursued vigorously.

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

35. J Perinatol. 2016 May;36 Suppl 1:S21-8.
Efficacy and safety of CPAP in low- and middle-income
countries.
Thukral A, Sankar MJ, Chandrasekaran A, Agarwal R, Paul VK.
Abstract
We conducted a systematic review to evaluate the (1) feasibility and
efficacy and (2) safety and cost effectiveness of continuous positive
airway pressure (CPAP) therapy in low- and middle-income countries
(LMIC). Pooled analysis of four observational studies showed 66%
reduction in in-hospital mortality following CPAP in preterm neonates
(odds ratio 0.34, 95% confidence interval (CI) 0.14 to 0.82). One study
reported 50% reduction in the need for mechanical ventilation following
the introduction of bubble CPAP (relative risk 0.5, 95% CI 0.37 to 0.66).
The proportion of neonates who failed CPAP and required mechanical
ventilation varied from 20 to 40% (eight studies). Available evidence
suggests that CPAP is a safe and effective mode of therapy in preterm
neonates with respiratory distress in LMICs. It reduces the in-hospital
mortality and the need for ventilation thereby minimizing the need for up-
transfer to a referral hospital.

36.  Nasal CPAP is an effective, safer and preferred mode of first
line therapy in the management of respiratory distress in
preterm neonates of all sizes.
 Early CPAP in preterm infants with respiratory distress also
reduces the need for surfactant therapy.
Take Home message