SCBU CPAP DR STEVE WONG

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CONTINUOUS POSITIVE AIRWAY PRESSURE TREATMENT FOR NEONATES

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SCBU CPAP DR STEVE WONG

  1. 1. Bubble CPAP Dr Steve Wong
  2. 2. CPAP <ul><li>CPAP = Continuous Positive Airway Pressure </li></ul><ul><li>CPAP is an effective noninvasive breathing support for newborn. </li></ul>
  3. 3. CPAP breathing support <ul><li>Ventilation via endotracheal tube </li></ul><ul><li>Nasal ventilation </li></ul><ul><li>Nasal CPAP </li></ul><ul><li>O2 nasal cannula </li></ul>
  4. 5. Concept of compliance <ul><li>The lung operates best at a level of optimum inflation. </li></ul><ul><li>At this optimum level, effort required for breathing is minimum (best compliance). </li></ul><ul><li>Newborns with respiratory distress secondary to under-inflation of lung are the best candidates. </li></ul>
  5. 6. Grunting & CPAP <ul><li>Newborns with mild respiratory distress and grunting are the typical best candidate for nasal CPAP </li></ul><ul><ul><ul><li>Grunting is a natural “CPAP” </li></ul></ul></ul>
  6. 7. How CPAP works <ul><li>Maintaining lung at optimum inflation </li></ul><ul><li>Maintaining upper airway patency (↓ apnoea) </li></ul><ul><li>Stimulation of breathing through airflow </li></ul><ul><li>Result: Improved oxygenation (↓ FiO2) Reduced work of breathing (↓ RR) </li></ul>
  7. 8. CPAP system <ul><li>Flow generator / oxygen blender </li></ul><ul><li>Heated humidifier </li></ul><ul><li>Pressure release “valve” </li></ul><ul><li>Nasal interface: nasal prongs </li></ul>
  8. 11. <ul><li>Pressure release valve </li></ul><ul><ul><ul><li>a valve with preset pressure </li></ul></ul></ul><ul><ul><ul><li>when pressure exceeds the preset pressure, airflow will be let out </li></ul></ul></ul><ul><ul><ul><li>different types: mechanical, underwater tube, computer controlled valve </li></ul></ul></ul>
  9. 12. CPAP: how it works <ul><li>At resting state </li></ul><ul><ul><ul><li>Flow generator generates a flow, with predefined FiO2 </li></ul></ul></ul><ul><ul><ul><li>Pressure inside the system is maintained by a “pressure release valve” </li></ul></ul></ul><ul><ul><ul><li>Some leaking is expected at nasal interface </li></ul></ul></ul>
  10. 13. <ul><li>During inspiration </li></ul><ul><ul><ul><li>Patient takes air from the system </li></ul></ul></ul><ul><ul><ul><li>Pressure within the system remains unchanged </li></ul></ul></ul><ul><ul><ul><li>Leak from the “pressure release valve” is reduced (but still leaking) </li></ul></ul></ul>
  11. 14. <ul><li>During expiration </li></ul><ul><ul><ul><li>Patient exhales </li></ul></ul></ul><ul><ul><ul><li>Exhaled air goes into the system </li></ul></ul></ul><ul><ul><ul><li>Leak from “pressure release valve” increases </li></ul></ul></ul><ul><ul><ul><li>Pressure inside the system remains unchanged </li></ul></ul></ul><ul><ul><ul><li>Exhaled air washed out by “leak” </li></ul></ul></ul>
  12. 15. CPAP for newborn <ul><li>Nasal CPAP: simple, yet sophisticated </li></ul><ul><li>To be effective, the whole setup has to be fine-tuned </li></ul><ul><ul><ul><li>Proper nasal interface </li></ul></ul></ul><ul><ul><ul><li>Proper CPAP setting </li></ul></ul></ul><ul><ul><ul><li>Maintenance of tubing patency </li></ul></ul></ul>
  13. 16. Nasal interface <ul><li>Nasal prongs </li></ul><ul><ul><ul><li>short prongs easier than long prongs </li></ul></ul></ul><ul><ul><ul><li>Hudson’s prongs better than INCA </li></ul></ul></ul><ul><ul><ul><li>Choose the right size: “just fit” </li></ul></ul></ul>
  14. 18. INCA nasal prongs Infant Nasal CPAP Assembly (INCA)
  15. 19. Nasal interface <ul><li>Fixation of the interface is very important </li></ul><ul><ul><ul><li>Fix on upper lip </li></ul></ul></ul><ul><ul><ul><li>Fix on the face </li></ul></ul></ul><ul><li>Minimise mouth leak </li></ul><ul><ul><ul><li>Pacifier, chin strap (both are effective) </li></ul></ul></ul>
  16. 20. Hudson: size guide <ul><li>Term baby: size 3 (size 4 in larger baby) </li></ul><ul><li>Near term baby: size 2 </li></ul>
  17. 25. Flow system <ul><li>Underwater bubble CPAP is simple, safe, and economical. </li></ul><ul><ul><ul><li>Risk of over-pressure is low </li></ul></ul></ul><ul><ul><ul><li>Theoretical advantage of “bubbling” </li></ul></ul></ul><ul><ul><ul><li>Easy monitoring of “bubble” </li></ul></ul></ul>
  18. 27. CPAP application <ul><li>Principles </li></ul><ul><ul><ul><li>Mild respiratory distress requiring short term modest respiratory support i.e. conditions that could be maintained by nasal cannula O2, but can be better with nasal CPAP </li></ul></ul></ul><ul><ul><ul><li>Maintenance of patients with mild to moderate respiratory distress awaiting transfer to ICU facilities </li></ul></ul></ul>
  19. 28. CPAP application <ul><li>Transient tachypnoea of newborn (“wet lung”) </li></ul><ul><li>Mild respiratory distress syndrome </li></ul><ul><li>Mild congenital pneumonia </li></ul>
  20. 29. CPAP application <ul><li>General guide: </li></ul><ul><ul><ul><li>FiO2 < 50% </li></ul></ul></ul><ul><ul><ul><li>Mild tachypnoea (RR < 80/min) </li></ul></ul></ul>
  21. 30. CPAP setting <ul><li>FiO2 </li></ul><ul><li>CPAP pressure (cm H2O) </li></ul><ul><ul><ul><li>2: ~ atmospheric </li></ul></ul></ul><ul><ul><ul><li>4: low setting </li></ul></ul></ul><ul><ul><ul><li>6: moderate setting </li></ul></ul></ul><ul><ul><ul><li>8: high setting (best avoided) </li></ul></ul></ul>
  22. 31. Positioning <ul><li>Supine (common) </li></ul><ul><li>Prone (possible) </li></ul>
  23. 32. CPAP failure <ul><li>Intolerance: improper setting or interface </li></ul><ul><li>Excessive leak: dummy, chin strap </li></ul><ul><li>Deterioration of condition: true failure of CPAP </li></ul>
  24. 33. Common problems <ul><li>Nasal interface </li></ul><ul><ul><ul><li>misplaced </li></ul></ul></ul><ul><ul><ul><li>leaking </li></ul></ul></ul><ul><ul><ul><li>pressure sore </li></ul></ul></ul><ul><ul><ul><li>excessive humidity / water at interface </li></ul></ul></ul><ul><ul><ul><li>mouth leak </li></ul></ul></ul>
  25. 34. <ul><li>Tubing problem </li></ul><ul><ul><ul><li>wrong connection </li></ul></ul></ul><ul><ul><ul><li>disconnection </li></ul></ul></ul><ul><ul><ul><li>excessive water in tubing </li></ul></ul></ul>
  26. 35. <ul><li>Gastric distension </li></ul><ul><ul><ul><li>Common </li></ul></ul></ul><ul><ul><ul><li>Insert orogastric tube OPEN to air all the time </li></ul></ul></ul>
  27. 37. Problems with setting <ul><li>Pressure setting too low </li></ul><ul><ul><ul><li>no / slow improvement, or deterioration </li></ul></ul></ul><ul><ul><ul><li>setting similar to that of nasal cannula O2 </li></ul></ul></ul>
  28. 38. <ul><li>Pressure setting too high </li></ul><ul><ul><ul><li>increased AP diameter of chest </li></ul></ul></ul><ul><ul><ul><li>no improvement, or deterioration </li></ul></ul></ul><ul><ul><ul><li>risk of air leak </li></ul></ul></ul>
  29. 39. CPAP failure <ul><li>Clear indication of failure </li></ul><ul><ul><ul><li>Persistent / frequent desaturation </li></ul></ul></ul><ul><ul><ul><li>FiO2 increasing, esp. if >50% </li></ul></ul></ul>
  30. 40. <ul><li>Inappropriate candidates </li></ul><ul><ul><ul><li>Haemodynamic instability i.e. low BP or poor perfusion </li></ul></ul></ul><ul><ul><ul><li>Central apnoea i.e. ill baby / asphyxia </li></ul></ul></ul><ul><ul><ul><li>Unstable upper airway </li></ul></ul></ul>
  31. 41. Risk of air leak <ul><li>Does use of nasal CPAP increase risk of air leak (pneumothorax)? </li></ul><ul><ul><ul><li>No </li></ul></ul></ul>
  32. 42. Weaning from CPAP <ul><li>Weaning started after initial stabilisation </li></ul><ul><li>Typically when FiO2 is ~30% </li></ul><ul><li>Weaning can be slow or rapid </li></ul>
  33. 43. Oral feeding and CPAP <ul><li>CPAP should be discontinued (switched to nasal cannula O2) during oral feeding, to minimise risk of aspiration. </li></ul><ul><li>Patients with significant respiratory distress should preferably be kept NPO or with tube feeding. </li></ul>

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