seminar on cpap dr poonam

1. WELCOME TO THE SEMINAR
Dr. Poonam Bodh
Dr. Nadia Hossain
Resident, year-3
Department of Neonatology
BSMMU

2. Scenario--1
 B/o Ayesha, PT(28wk) extremely low birth weight(900g)
admitted into NICU due to prematurity and low birth weight.
On day-3 baby developed repeated apnea, in between attack
baby had spontaneous respirations and reflex activities were
good.During attack baby was euglycemic, well- perfused ,
normothermic

3.  S/o Labonno,PT(30 wks)VLBW(1250 gm) admitted into NICU with
the complaints of born before date,LBW,respiratory distress soon
after birth.Baby was on MV for last 5 days.according to clinical
improvement as well as blood gas monitoring,decided to wean from
MV.
2

4. B/O Tania, term (34+wk) LBW (1600g) admitted into NICU with
the complaints of respiratory distress soon after birth in the
form of tachypnoea, upper and severe chest retraction,
grunting. Mother had no history of taking antenatal
corticosteroids.
3

5. What will be our initial management

6. CPAP SUPPORT

7. Headlines
 Definition
 History
 Types of CPAP
 Advantages and disadvantages
 Devices used for CPAP delivery
 How CPAP works and effects
 Indications
 contraindications

8.  Essentials of CPAP
 Care of new born on CPAP
 How to monitor while on CPAP?
 Complication
 Procedures of removal of CPAP
 CPAP failure
 Take home message

9. CPAP

10. Definition
 CPAP refers to the application of positive pressure to the
airway of a spontaneously breathing infant through out the
respiratory cycle.

11. HISTORY
 The first clinical use of CPAP was reported by Gregory et al in a landmark
report in 1971.
 After the initial enthusiasm, it gradually fell out of favor in 1980s because of
the advent of newer modes of ventilation.
 However, reports of significantly lower incidence of chronic lung
disease (CLD) from Columbia University unit that used more CPAP as
compared to other North American Centers have led to resurgence of
interest in CPAP over the past 15 years.

12. Types of CPAP:

14. Advantages and disadvantages of different
CPAP

15. Devices Advantages Disadvantages
Conventional ventilator derived
CPAP
•No need of a separate
equipments
•Can be easily switched over to
MV if CPAP fails
•Expensive
•Presence of high leak
•Difficult to know set flow is
sufficient or not
Stand-alone CPAP machines •Economical
•Useful for small hospitals
•Can have bubble CPAP option
•Most of them do not have
proper blenders and /or
pressure manometer
Bubble CPAP •Simple and inexpensive
•Oscillations produced by
continuous bubbling contribute
gas exchange
•Flow has to be altered to
ensure proper bubbling
•It is difficult to detect high flow
which lead to over-distension of
the lung.

16. Devices used for CPAP delivery
 Various devices used for CPAP delivery include:
1. Nasal prongs (single/double or binasal)
2. Long (or) nasopharyngeal prongs
3. Nasal cannula
4. Nasal masks.
 Face mask, endotracheal, and head box are no longer used for CPAP delivery in
neonates. Endotracheal CPAP is not recommended because it has been found
to increase the work of breathing (infant has to breathe ‘through a straw’).

17. CPAP delivery systems
1
2
3
4
Fig:
1. Nasal mask
2. Nasal prong
3. Long
nasopharyngeal
prong
4. ET tube

18. Advantages disadvantages of CPAP delivery
devices

19. Delivery systems Advantages Disadvantages
Nasal prongs Simple
Lower resistance leads to
greater transmission of pressure
Difficult to fix
Risk of trauma of nasal septum
Nasopharyngeal prongs Easy availability
Economical
More secure fixation
More easily block by secretions
Likely to get kinked.
Nasal cannulae Ease of application Unreliable pressure delivery
Need high flow to generate
pressure
Large leaks around cannula.
Nasal mask Minimal nasal trauma Difficulty in obtaining an
adequate seal

20. Parts of CPAP:

21. CPAP machines in our NICU
Fig: oxygen concentrator CPAP Fig: BUBBLE CPAP

22. How CPAP works?

24. Indications for CPAP

25. 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.
 Once atelectasis and collapse have occurred, CPAP might not help
much.

26.  Any signs of significant respiratory distress
 Tachypnoea
 flaring
 grunting
 retractions
 cyanosis
 O2 requirement
 Diseases with low functional residual capacity (FRC)
 RDS
 TTN
 Pulmonary oedema
 Meconium Aspiration Syndrome
 Airway closure disease
 BPD
 Bronchiolitis
 Apnoea and bradycardia of prematurity
 Weaning from mechanical ventilation
 Tracheomalacia
 Diaphragmatic paralysis
Source: Newborn Services Clinical Guideline(US)

27. Prophylactic 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.

28. Prophylactic nasal continuous positive airway pressure for
preventing morbidity and mortality in very preterm infants
Cochrane Systematic Review - Intervention Version published: 14
June 2016
Seven studies involving 3123 infants.
In the four studies (765 babies) comparing CPAP with supportive care,
CPAP resulted in fewer infants requiring further breathing assistance.
In the three studies (2354 babies) that compared CPAP with assisted
ventilation with or without surfactant, CPAP resulted in a small but clinically
important reduction in BPD and the combined outcome of BPD and mortality.
There was a reduction in the need for mechanical ventilation and the use of
surfactant in the CPAP group.

30. A U T H O R ʼS C O N C L U S I O N S
 Use of nasal intermittent positive pressure ventilation (NIPPV) and
nasal continuous positive airway pressure (NCPAP) after extubation
reduces the incidence of extubation failure within 48 hours to seven
days. Studies using synchronized NIPPV and delivering NIPPV to
infants by a ventilator observed benefits more consistently.
Investigators noted no overall reduction in chronic lung disease
among infants randomized to NIPPV and reported a reassuring
absence of the gastrointestinal side effects that had been reported in
previous case series

31. CPAP is considered to be adequate if a baby on
CPAP is
 Comfortable
 Has minimal or no chest retractions
 Has normal CFT, blood pressure
 SpO2 is between 90-95%
 Blood gas:
 PaO2 is 50 to 80 mmHg
 PCO2 is 40 to 60 mmHg
 pH is 7.35 to 7.45

32. Study of CPAP in Bangladesh

34. 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

35. 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

37. Setting and Role of Pressure, FiO2 and flow
 Pressure:
 Ideal range of pressure is from 4 cm to 8 cm of water
 Increase or decrease pressure to minimize chest retractions and to
maintain PaO2 > 50mm Hg
 FiO2:
 Ideal FiO2 is from 21% to 60%
 It is adjusted to maintain SPO2 between 90% to 95%
Always increase
pressure before
FiO2 for better
oxygenation
Ref: Work shop on CPAP, AIIMS, New Delhi,
2017

38.  Flow:
 Range of flow is from 5 to 8 L /min
 Flow changes are made only for delivering adequate pressure
To high flow results in wastage of gases, turbulence and inadvertent high pressure

39. 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

40. 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

41. 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.

42. 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.

43.  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

44.  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

45. 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 gastric aspirates to prevent
CPAP belly syndrome
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

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

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

48. • 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

49. 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

50. • 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

51. Trauma due to Nasal Mask

52. 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: This study to investigate the efficacy of the silicon gel application on the nares in prevention
of nasal injury in preterm infants ventilated 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.

53. Comparison of Nasal Mask Versus Nasal Prongs for Delivering
Nasal Continuous Positive Airway Pressure in Preterm Infants
with Respiratory Distress Syndrome (unpublished)
Thesis work: Dr Bipin Karki
Department of Neonatology, BSMMU Shahbagh, Dhaka, Bangladesh
October-2017
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.
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.

54. 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.

55. 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.

56. 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
Gaseous distension

57. 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.
The 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.

58. 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.
o 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).
o Nasal CPAP is associated with increased colonization with gram-negative bacilli.

59. 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 (18-22 months of corrected age), 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.

60. • 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

61.  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
 Keep it open for the next 90 minutes (if fed 2hourly)
Feeding While on CPAP

62.  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.
After removal from CPAP..

63.  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

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

65. 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.

66. 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.

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

68. 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.
o 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).
o The proportion of neonates who failed CPAP and required mechanical ventilation varied from 20 to
40% (eight studies).
o 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.

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

71. WELCOME TO THE SEMINAR
Dr. Poonam Bodh
Dr. Tareq Rahman
Resident, year-4
Department of Neonatology
BSMMU

72. Headlines
 Criteria of CPAP failure with failure rates
 Clinical
 ABG
 Causes of CPAP failure
 Infant Characteristics
 Predictors of CPAP failure
 Diligent nursing care and experience of Using CPAP
 Outcome of CPAP Failure

73. Failure of CPAP
 CPAP failure is considered;
- FiO2 > 60%
- Pressure > 7 cm of water
- A baby continuing to have retractions, grunting and
recurrent apnea on CPAP
- Inability to maintain SpO2 > 90% or PaO2 < 50 mm of Hg
with FiO2 ≥ 60% and pressure > 7cm of water and
PaCO2 > 60 mm of Hg, PH < 7.25

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

75. Table 1: Criteria for CPAP failure with failure rates in preterm infants
Failure
Rate
(25-26
wks)
55%
(27-28
wks)
40%
Early
CPAP –
39%
Insure –
26%
67.1%

76. CPAP
Group –
33%
Insure
group –
33.4%
17.9 % in
CPAP
group

77. The factors determining the success of CPAP
 choosing the right infant (weight and underlying disease
process), applying it early rather than late.
 knowing the machine well, diligent nursing care and the
conviction of the team.
 The threshold criteria used to define failure, will determine
the CPAP failure rates. With increasing experience the
success rates are likely to improve.

78. Infant characteristics
 Very small babies (< 750 grams) may not have good
respiratory efforts while term babies may not tolerate the
nasal prongs. CPAP is likely to have least failures in babies
between 750-1750 grams, but it can be successful in smallest
and bigger babies.
 CPAP is most successful in babies with mild to moderate
respiratory disease especially hyaline membrane disease and
apnea of prematurity.
 It is less likely to be successful in babies with CNS pathology
e.g. severe asphyxia or systemic sepsis.
 Babies exposed to antenatal steroids are likely to have milder
disease and more likely to succeed with CPAP.

79. J Pediatr 2005;147:341-7
VARIABLES ASSOCIATED WITH THE EARLY FAILURE OF NASAL CPAP IN VERY
LOW BIRTH WEIGHT INFANTS
AMER AMMARI, MB, BS, MANDHIR SURI, MD, VLADANA MILISAVLJEVIC, MD, RAKESH SAHNI, MD,
DAVID BATEMAN, MD, ULANA SANOCKA, MD, CARRIE RUZAL-SHAPIRO, MD, JEN-TIEN WUNG, MD,
AND RICHARD A. POLIN, MD
Results :
CPAP was successful in 76% of infants #1250 g birth weight and 50% of infants #750
g birth weight. In analyses adjusted for postmenstrual age (PMA) and small for
gestational age (SGA), CPAP failure was associated with need for positive pressure
ventilation (PPV) at delivery, alveolar-arterial oxygen tension gradient (A-a DO2)
>180 mmHg on the first arterial blood gas (ABG), and severe RDS on the initial chest
x-ray (adjusted odds ratio [95% CI] = 2.37 [1.02, 5.52], 2.91 [1.30, 6.55] and 6.42
[2.75, 15.0], respectively). The positive predictive value of these variables ranged
from 43% to 55%. In analyses adjusted for PMA and severe RDS, rates of mortality
and common premature morbidities were higher in the CPAP-failure group than in the
CPAP-success group.
Conclusion:
Although several variables available near birth were strongly associated with early
CPAP failure, they proved weak predictors of failure. A prospective controlled trial is
needed to determine if extremely premature spontaneously breathing infants are
better served by initial management with CPAP or mechanical ventilation.

80. Neonatology.2013;104(1):8-14.
Continuous positive airway pressure failure in preterm infants: incidence,
predictors and consequences.
Dargaville PA, Aiyappan A, De Paoli AG, Dalton RG, Kuschel CA, Kamlin CO, Orsini F, Carlin JB, Davis PG
METHODS:
Preterm infants 25-32 weeks' gestation were included in the study if inborn and managed with CPAP
as the initial respiratory support, with division into two gestation ranges and grouping according to
whether they were successfully managed on CPAP (CPAP-S) or failed on CPAP and required
intubation <72 h (CPAP-F). Predictors of CPAP failure were sought, and outcomes compared
between the groups.
RESULTS:
297 infants received CPAP, of which 65 (22%) failed, with CPAP failure being more
likely at lower gestational age. Most infants failing CPAP had moderate or severe
respiratory distress syndrome radiologically. In multivariate analysis, CPAP failure
was found to be predicted by the highest FiO₂ in the first hours of life. CPAP-F
infants had a prolonged need for respiratory support and oxygen therapy, and a
higher risk of death or bronchopulmonary dysplasia at 25-28 weeks' gestation
(CPAP-F 53% vs. CPAP-S 14%, relative risk 3.8, 95% CI 1.6, 9.3) and a
substantially higher risk of pneumothorax at 29-32 weeks.
CONCLUSION:
CPAP failure in preterm infants usually occurs because of unremitting respiratory
distress syndrome, is predicted by an FiO₂ ≥0.3 in the first hours of life, and is
associated with adverse outcomes.

81. 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.
o 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).
o The proportion of neonates who failed CPAP and required mechanical ventilation
varied from 20 to 40% (eight studies).
o 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.

85. Diligent Nursing Care and Experience of Using CPAP
The quality of nursing care is equally important in deciding overall
success rate. The attention should be given to all the details including
clinical frequent examination of Infants;
 Baby is not fighting the CPAP interface
• Nasal prongs or nasal masks are of correct size and are in position
• Humidification is adequate and there is no condensation in the
circuit
• Adequate pressure and FiO2, are delivered (neck position, clear
nostrils and airway)

86. Pediatrics,2004 Sep;114(3):697-702.
Does the experience with the use of nasal continuous positive airway
pressure improve over time in extremely low birth weight infants?
Aly H, Milner JD, Patel K, El-Mohandes AA.
RESULTS:
There were no significant trends in mortality rate among the baseline group and the 3 terciles since
the institution of the ENCPAP practice (26.7% vs 26.5% vs 11.8% vs 18.2%). ENCPAP
management increased in the surviving infants over time (14% vs 19.2% vs 65.52% vs 70.4%),
whereas the use of surfactant decreased (51.5% vs 48% vs 13.3% vs 33.3%) and the incidence of
bronchopulmonary dysplasia (BPD) decreased (33.3% vs 46.2% vs 25.9% vs 11.1%). The average
ventilator days per infant decreased, the rate of sepsis decreased, and the average daily weight
gain increased. There were no significant trends in the incidence of intraventricular hemorrhage or
necrotizing enterocolitis (NEC). When comparing the cohorts of survivors in the 3 terciles since the
institution of ENCPAP system, ELBW infants who were started on ENCPAP but intubated within 1
week (CPAP failure) decreased over time (38.5% vs 13.8% vs 7.4%). There were other trends that
did not reach significance, such as increased incidence of necrotizing enterocolitis (NEC). In a
multivariate analysis controlling for gestational age, birth weight, and sepsis, the incidence of BPD
was significantly lower over time (regression coefficient = -1.002 +/- 0.375).
CONCLUSIONS:
The frequency of use of ENCPAP in ELBW infants and its success improved in our unit over time.
The major positive association in this population was a reduction in BPD rates and an increase in
average weight gain. Relation of ENCPAP and NEC should be evaluated further.

87. Pediatrics. 2016;138(1)
Incidence and Outcome of CPAP Failure in Preterm Infants
Peter A. Dargaville, FRACP, MD, Angela Gerber, MD, Stefan Johansson, MD, Antonio G. De Paoli, FRACP, MD,
Omar F. Kamlin, FRACP, DMedSci, Francesca Orsini, BSc, MSc, Peter G. Davis, FRACP, MD.
METHODS:
Data from inborn preterm infants managed on CPAP from the outset were analyzed in 2
gestational age ranges (25–28 and 29–32 completed weeks). Outcomes after CPAP failure
(need for intubation < 72 hours) were compared with those succeeding on CPAP using adjusted
odds ratios (AORs).
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.