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Cpap

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CPAP SCIENCE,WORKSHOP,THERAPY,PRACTICE,INDICATION,RDS,MSAL,

MAS,APNEA OF PREMATURITY,PNEUMONIA,SEPTICEMIA

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Cpap

  1. 1. CPAP- SCIENCE INDICATION AND APPLICATION PRESENTED BY  DR NISHANT PRABHAKAR  MD PEDIATRICS
  2. 2. DEFINITION  Also called continuous distending pressure (CDP)  Maintenance of an increased (positive) transpulmonary pressure during the inspiratory & expiratory phase of respiration in a spontaniously breathing baby.  By which alveoli are kept open which increase the functional residual capacity(FRC) of the lungs resulting in better gas exchange.
  3. 3. HISTORY  Harrison 1968: described grunting in neonates as naturally producing end expiratory pressure  Gregory et al, 1971: introduced the clinical use of distending pressure in neonates.(via endotrachial tube or a head box)  Kattwinkel reported successful use of nasal prongs in neonates with RDS.  Reports of significant lower incidence of chronic lung disease from columbia university that used more CPAP as compared to north american centre have led to resurgence of interest in CPAP over the last 15 years.
  4. 4. PHYSIOLOGY OF CPAP  Increases FRC  Decreases V/Q mismatch  Splints upper airway - airway resistance  Increase tidal volume  Decrease work of breathing  Conserves surfectant  Increase lung compliance
  5. 5. DISADVANTAGES OF CONVENTIONAL VENTILATION  High pressure- Barotrauma  Tidal volumes- Volutrauma  Atelectotrauma  Inflammation & infection- Biotrauma  CV ruptures the interalveolar septa thus decrease the surface area of gas exchange despite increasing lung volume.
  6. 6. Effect of Ventilator on Preterm Lamb Lung  At 0 hour  24 hour after ventilation  Limitations of premature lung  1.Underdeveloped architect to hold the lung open  2.Thicker and few septa so less SA for gas exchange  Pinkerton KE, et al J Appl Physiol, 1994
  7. 7. Preterm Lambs at 72 Hours Distal Airspace Wall Thickness -  CV nCPAP
  8. 8. VENTILATOR INDUCED LUNG INJURY (VILI)  Biotrauma with tube  atelectotrauma
  9. 9. VENTILATOR INDUCED LUNG INJURY (VILI)  Barotrauma  Volutrauma
  10. 10. ADVANTAGE OF CPAP 1. Effect on lung growth- increased protein and DNA
  11. 11. 2- increased lung compliance
  12. 12. PVR Increases at Lung Volumes Below and Above FRC PVR Lung Volume FRC HMD MAS
  13. 13. CPAP MAGIC  Opens lung at FRC  Keeps it open at minimum constant pressure least atelecto & barotrauma  Pulmonary arterial pressure are least hence less V/Q mismatch less pressure required.  No ET tube- no biotrauma
  14. 14. Larger alveolus r = 1.5 T = 3 P = (2 x 3) / 1.5 P = 4 Smaller alveolus r = 1 T = 3 P = (2 x 3) / 1 P = 6 CPAP Law of LaPlace : P = 2T/r P : pressure T : surface tension r : radius
  15. 15. How does CPAP works
  16. 16. Stretches lung pleura and upper airway  CPAP Prevents collapse of alveoli with marginal stability Stabilizes the chest wall Splints open upper airway Improves pH Reduces airway resistance Recruitment of alveoli PaO2PaCO2 Improves V/Q mismatch and reduces intrapulmonary shunt Increased alveolar surface area for gas exchange Maintains lung at FRC Reduces work of breathing Reduces mixed and central apnea Reduces obstructive apnea Stimulates stretch receptors
  17. 17. INDICATION OF CPAP  COMMON  Respiratory distress syndrome  Apnea of prematurity (specially obstructive apnea)  Post-extubation in preterm VLBW infants  Transient tachypnea of newborn (TTNB)  OTHER INDICATION  Pneumonia  Meconium aspiration/other aspiration syndrome  Pulmonary edema/pulmonary hemorrhage  Laryngomalacia/tracheomalacia/bronchomalacia
  18. 18. Early CPAP in RDS  was proved to be more beneficial in the atelectatic disease  lower peak pressure required in infants treated with CPAP  enhance surfactant conservation  reduce the need for IMV by 20%, except infants with birth weight <1500 g.  improve mortality and decrease the incidence of BPD  prevent need for prolong intubation which reduce the incidence of acquired subglottic stenosis
  19. 19. Failure of CPAP therapy in RDS  very low birth weight infant  late application of CPAP  severity of RDS  associated disease e.g. sepsis, hypotension  infants with severe degree of extrapulmonary shunt  (Fox and coworkers, 1977)
  20. 20. CPAP in apnea of prematurity  the application of low-level CPAP decrease the incidence of apnea of prematurity (compared to other forms of stimulation)  improve oxygenation  stimulation or inhibition of pulmonary reflexes  alveolar stabilization  mechanical splinting of airway; reduce supraglottic resistance in both inspiration and expiration  some investigators recommended the early use of CPAP as a preventive measure of apnea of prematurity
  21. 21. CPAP IN INFANTS WITH MAS  pathology of meconium aspiration  atelectasis  large airway obstruction  V/Q abnormalities  application of low-to moderate level CPAP  resolution of atelectasis  stabilization of terminal airway  incidence of pneumothorax: not increased  precautions in case with PPHN
  22. 22. C0NTRAINDICATION OF CPAP  Progressive respiratory failure with PaCO2 levels >60 mmhg and/or inability to maintain oxygenation (PaCO2 <50 mmHg)  Certain congenital malformation of the airway (choanal atresia, cleft palate, tracheoesophageal fistula, congenital diaphragmatic hernia,etc)  Severe cardiovascular instability (hypotension)  Poor respiratory drive (frequent apnea and bradycardia) that is not improved by CPAP.
  23. 23. ESSENTIALS OF CPAP
  24. 24. CPAP MACHINES  An ideal CPAP delivery system consists of:  A continuous supply of warm, humidified, blended gases at a flow rate of 2-3 times the infant minute ventilation.  A device to connect CPAP circuit to infants airway.  Means of creating a positive pressure in CPAP circuit.
  25. 25. CPAP DELIVERY SYSTEM  Ventilator : ideal system to provide CPAP but very costly  CPAP system : should have 1. End expiratory pressure of 0-15 cm of water. 2. Humidification of upto 100% 3. Gas flow 5-8 L/min 4. Warming of gases to 34-37˚c 5. Blending oxygen-air mixture FiO2 0.21-1.0 6. Low noise compressor 7. Compatibility to run days & weeks 8. Reasonable cost
  26. 26. PATIENT INTERFACE FOR PROVIDING CPAP  Nasal prongs 1-Fisher & paykel 2-Hudson 3-Argyl nasal prong
  27. 27. CPAP DEVICES
  28. 28. SETTING PRESSURE, FLOW & FiO2 1. Pressure- regulated by depth of immersion of expiratory limb(water level being constant).start with 5 cm water in case of RDS or pneumonia and 4 cm water for apnea management.(range- 4-8) 2. Flow- it should be minimal to produce bubbling in the bubble chamber(2-5 L/min is sufficient) 3. FiO2- start with a FiO2 of 40 to 50% and after adjusting the pressure,titrate FiO2 to maintain SpO2 between 89% to 94%.
  29. 29. MONITORING ADEQUACY AND COMPLICATION OF CPAP
  30. 30. MONITORING THE INFANT CONDITION  Recommended monitoring: • Respiratory status (RR, work of breathing) • Pre ductal oxygen saturation • Cardiovascular status (HR, BP, perfusion) • GI status (abdominal distention, bowel sounds) • Neurological state (tone, activity, responsiveness) • Thermoregulation (temp)
  31. 31. WEANING FROM CPAP  It is considered when clinical condition for which CPAP was indicated is passive.  e.g. in case of RDS we have to see for improvement in Silverman Anderson score i.e. if score is less than 4 we can try weaning
  32. 32. SILVERMAN ANDERSON SCORE  Score >7 –respiratory failure  Score 4-7 –respiratory distress
  33. 33. WEANING FROM CPAP  CPAP for apnea may be removed after 24 -48 hrs of apnea free interval.  If the baby is stable on CPAP,first wean off the oxygen in steps of 5% and then wean PEEP to minimum of 4cm in step of 1cm/change.  When baby is in FiO2<30%, PEEP 4cm, with normal saturation and minimal retraction CPAP can be removed.
  34. 34. CPAP FAILURE  CPAP failure is considered if FiO2 required is >60% and PEEP required is > 7cm of water.  If baby is continuing to have retraction, grunting and apnea is considered fo mechanical ventilation.  If PaO2<50%, SpO2<85%, and PaCO2>60% on CPAP with FiO2>60% and PEEP >7cm of water is also considered for mechanical ventilation.
  35. 35. BEFORE CONSIDERING CPAP FAILURE ENSURE THE FOLLOWING
  36. 36. Maintaining Optimal Airway Care: Humidification • 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 temperature to 36.8- 37.3o C.
  37. 37. Complications associated with bubble nasal CPAP  ● Pneumothorax / PIE - more in the acute phase - not a contraindication for continuing CPAP  ● Nasal obstruction - Remove secretions and check for proper positioning of the prongs  ● Nasal septal erosion or necrosis - Keep prongs away from the septum  ● Gastric distension  Intermittent or continuous aspiration of the stomach  ● Feeding intolerance
  38. 38. Preventing Complications: Gastric Distention • NCPAP is not a contraindication to enteric feeding. • Infants may experience mild abdominal distention during NCPAP delivery from swallowing air.
  39. 39. CPAP BELLY
  40. 40. Preventing Complications: Gastric Distention  To prevent gastric distention: • Assess the infant’s abdomen regularly • Pass an oro-gastric tube to aspirate excess air before feeds q 2-4 hr • An 8 Fr oro-gastric tube may be left indwelling to allow for continuous air removal
  41. 41. CASE STUDY  Antenatal steroid  Arrangement before birth
  42. 42. Exercise

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