This document provides an overview and discussion of CPAP (continuous positive airway pressure) usage in neonates. It begins with three case scenarios of premature infants admitted to the NICU and then poses the question of initial management. The bulk of the document discusses CPAP, including definitions, history, types, advantages/disadvantages, devices, effects, indications, contraindications, essentials, monitoring, complications, weaning and more. Studies on CPAP usage in Bangladesh and methods of weaning are also summarized.
This document provides an overview of a seminar on CPAP in neonatal practice. It includes two case scenarios of premature infants with respiratory distress and then outlines what CPAP is, the history of its use, types of CPAP devices, how CPAP works, indications and contraindications for its use, essentials of providing CPAP including monitoring infants on CPAP and managing complications. Studies are summarized that show benefits of CPAP for preventing morbidity and mortality in premature infants as well as its use after extubation. Guidelines are provided on initiating, maintaining and weaning infants from CPAP support.
A preterm newborn developed respiratory distress soon after birth, with signs including grunting and cyanosis. Evaluation found respiratory distress syndrome (RDS). The baby was treated with nasal CPAP, surfactant, and mechanical ventilation. RDS is caused by surfactant deficiency in premature infants, resulting in alveolar collapse and impaired gas exchange. Management includes respiratory support, surfactant replacement therapy, and care to prevent complications.
NON INVASIVE VENTILATION IN NEONATES-PART 1Adhi Arya
Non-invasive ventilation techniques like nasal continuous positive airway pressure (nCPAP) are increasingly used for preterm neonates with respiratory distress to avoid intubation and invasive ventilation. nCPAP uses nasal prongs or a mask to deliver continuous distending pressure throughout the respiratory cycle. Evidence shows nCPAP reduces the need for mechanical ventilation and postnatal steroids compared to prophylactic surfactant without increasing adverse outcomes. Proper patient interface selection, initial pressure settings, and troubleshooting are important for safe and effective nCPAP use in neonates.
This document discusses several common respiratory diseases that can affect newborns, including respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), primary pulmonary hypertension of the newborn (PPHN), and apnea of prematurity. It provides details on the causes, clinical presentations, diagnoses and management of each condition. The document is intended to educate medical professionals such as pediatricians on recognizing and treating respiratory issues in newborns.
HFNC therapy is an alternative to CPAP for respiratory support of neonates. It works by flushing the nasal passages and removing exhaled gases, reducing dead space and resistance. HFNC provides a dynamic distending pressure of 3-5 cm H2O. It is indicated for mild respiratory dysfunction post-extubation or as an alternative to CPAP. Evidence shows HFNC has similar efficacy to CPAP with no differences in rates of reintubation, treatment failure, death or chronic lung disease when used for primary support or post-extubation. HFNC allows for a longer duration of non-invasive respiratory support.
- Childhood tuberculosis is challenging to diagnose due to difficulties in confirming infection status and obtaining bacteriological confirmation.
- Risk of developing active TB is highest in the first two years of life, with disseminated disease and mortality also more common in young children.
- Diagnosis relies on clinical features, radiology, tuberculin skin testing, and bacteriological confirmation through sputum/gastric aspirate sampling and culture.
- Treatment guidelines in India recommend 6 months of chemotherapy for all childhood contacts of active TB cases, and clinically diagnosed cases can now begin treatment if confirmation testing is negative.
Non-Invasive Ventilation for Preterm InfantsMark Weems
This document discusses non-invasive ventilation techniques for preterm infants. It begins with a brief history of ventilation methods, including early attempts at non-invasive oxygen delivery and invasive techniques like intubation that introduced complications. More recent non-invasive methods described include high-flow nasal cannula (HFNC), nasal continuous positive airway pressure (NCPAP), and non-invasive positive pressure ventilation (NIPPV). Several studies comparing these techniques are summarized, finding that NCPAP and well-designed NIPPV protocols can reduce the need for intubation and the risk of bronchopulmonary dysplasia compared to early intubation and ventilation. Precise delivery of pressures using the Ram Cannula interface is also discussed.
This document provides an overview of a seminar on CPAP in neonatal practice. It includes two case scenarios of premature infants with respiratory distress and then outlines what CPAP is, the history of its use, types of CPAP devices, how CPAP works, indications and contraindications for its use, essentials of providing CPAP including monitoring infants on CPAP and managing complications. Studies are summarized that show benefits of CPAP for preventing morbidity and mortality in premature infants as well as its use after extubation. Guidelines are provided on initiating, maintaining and weaning infants from CPAP support.
A preterm newborn developed respiratory distress soon after birth, with signs including grunting and cyanosis. Evaluation found respiratory distress syndrome (RDS). The baby was treated with nasal CPAP, surfactant, and mechanical ventilation. RDS is caused by surfactant deficiency in premature infants, resulting in alveolar collapse and impaired gas exchange. Management includes respiratory support, surfactant replacement therapy, and care to prevent complications.
NON INVASIVE VENTILATION IN NEONATES-PART 1Adhi Arya
Non-invasive ventilation techniques like nasal continuous positive airway pressure (nCPAP) are increasingly used for preterm neonates with respiratory distress to avoid intubation and invasive ventilation. nCPAP uses nasal prongs or a mask to deliver continuous distending pressure throughout the respiratory cycle. Evidence shows nCPAP reduces the need for mechanical ventilation and postnatal steroids compared to prophylactic surfactant without increasing adverse outcomes. Proper patient interface selection, initial pressure settings, and troubleshooting are important for safe and effective nCPAP use in neonates.
This document discusses several common respiratory diseases that can affect newborns, including respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), primary pulmonary hypertension of the newborn (PPHN), and apnea of prematurity. It provides details on the causes, clinical presentations, diagnoses and management of each condition. The document is intended to educate medical professionals such as pediatricians on recognizing and treating respiratory issues in newborns.
HFNC therapy is an alternative to CPAP for respiratory support of neonates. It works by flushing the nasal passages and removing exhaled gases, reducing dead space and resistance. HFNC provides a dynamic distending pressure of 3-5 cm H2O. It is indicated for mild respiratory dysfunction post-extubation or as an alternative to CPAP. Evidence shows HFNC has similar efficacy to CPAP with no differences in rates of reintubation, treatment failure, death or chronic lung disease when used for primary support or post-extubation. HFNC allows for a longer duration of non-invasive respiratory support.
- Childhood tuberculosis is challenging to diagnose due to difficulties in confirming infection status and obtaining bacteriological confirmation.
- Risk of developing active TB is highest in the first two years of life, with disseminated disease and mortality also more common in young children.
- Diagnosis relies on clinical features, radiology, tuberculin skin testing, and bacteriological confirmation through sputum/gastric aspirate sampling and culture.
- Treatment guidelines in India recommend 6 months of chemotherapy for all childhood contacts of active TB cases, and clinically diagnosed cases can now begin treatment if confirmation testing is negative.
Non-Invasive Ventilation for Preterm InfantsMark Weems
This document discusses non-invasive ventilation techniques for preterm infants. It begins with a brief history of ventilation methods, including early attempts at non-invasive oxygen delivery and invasive techniques like intubation that introduced complications. More recent non-invasive methods described include high-flow nasal cannula (HFNC), nasal continuous positive airway pressure (NCPAP), and non-invasive positive pressure ventilation (NIPPV). Several studies comparing these techniques are summarized, finding that NCPAP and well-designed NIPPV protocols can reduce the need for intubation and the risk of bronchopulmonary dysplasia compared to early intubation and ventilation. Precise delivery of pressures using the Ram Cannula interface is also discussed.
The document describes three case scenarios involving newborn infants with respiratory distress. The first case involves an infant born at 30 weeks gestation who developed respiratory distress soon after birth and was normothermic, euglycemic, and had good reflexes and activity. The second case involves an infant born at 31 weeks gestation who was started on oxygen and later developed progressive respiratory distress, with CPAP initiated after the Downe's score reached 5 at 3 hours of age. The third case involves an infant born at 30 weeks gestation who was initially put on CPAP but required increased settings and eventually surfactant and mechanical ventilation due to inability to maintain saturation on CPAP. The document seeks management recommendations for each case.
Apnea of prematurity is the most common respiratory problem in premature infants, prolonging hospitalization. It is defined as a cessation of breathing for 20 seconds or less if accompanied by bradycardia or cyanosis. Incidence and severity are inversely related to gestational age, with 50% of infants under 1500g requiring intervention. Proposed causes include immaturity of the respiratory center, decreased afferent input, abnormal reflexes, and hypoxemia. Treatment focuses on stimulation, treating underlying causes, methylxanthines to stimulate breathing, and CPAP for severe or refractory cases. Methylxanthines like caffeine are the first line treatment but CPAP may be used if apnea is not resolved
This presentation is all about how to run a high risk follow up clinic for newborns discharged from a level II/III newborn care unit. It has been prepared mainly based on NNF protocol & AIIMS protocol.
This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
This document provides an overview of newborn resuscitation by Dr. Lokanath Reddy from the Department of Paediatrics at Kasturba Medical College in Manipal, India. It covers the history and principles of newborn resuscitation, initial steps, positive pressure ventilation, intubation, medications, special considerations for preterm babies, and ethics. Causes of neonatal compromise are discussed. Guidelines for newborn resuscitation from various medical organizations over time are summarized.
hhhfnc 2019,karneocon,vijayapura - Dr Karthik Nageshkarthiknagesh
High Flow Nasal Canula (HFNC) therapy in Neonates - Applications discusses the use of HFNC therapy in neonates as an alternative to invasive ventilation and CPAP. It provides an overview of the evidence and clinical settings where HFNC is indicated. It describes how HFNC works and guidelines for its use. The document also discusses some of the problems with more invasive forms of ventilation and how HFNC aims to provide respiratory support in a less invasive manner.
1. The pediatric ECG document reviews cardiac physiology and ECG findings in children of different ages. It discusses how the size of the ventricles changes from birth through childhood and how this impacts ECG measurements.
2. Key aspects of the normal pediatric ECG are described, including typical heart rates, axis shifts, and "juvenile" T wave patterns. Common abnormalities seen in pediatric patients such as chamber enlargement, conduction abnormalities, and arrhythmias are also reviewed.
3. The document provides guidance on interpreting ECG findings and correlating them to possible diagnoses in children, taking into account how measurements may differ based on age. Examples of ECG strips are included to illustrate various normal and abnormal
CPAP therapy provides positive airway pressure throughout the respiratory cycle to help stabilize the lungs. It has various physiological effects like decreasing respiratory rate and increasing functional residual capacity. CPAP can be applied through nasal prongs, masks, or endotracheal tubes. It is commonly used to treat respiratory distress syndrome, meconium aspiration syndrome, and apnea of prematurity. Optimal CPAP levels depend on the underlying lung disease and physiology. CPAP is generally well-tolerated but high levels can cause side effects like air leaks or decreased cardiac output. Close monitoring is needed when applying and weaning infants from CPAP support.
This document discusses apnea in infants and sudden infant death syndrome (SIDS). It defines apnea, describes the different types (obstructive, central, mixed), and potential causes. It outlines the clinical presentation of apnea and treatment options, including caffeine/theophylline. Though apnea is more common in preterm infants, it does not increase the risk of SIDS. The prognosis is generally good unless apnea is severe and refractory to treatment. SIDS is defined as the sudden unexpected death of an infant under 1 year that remains unexplained after autopsy. Risk factors include prematurity, sleeping in the prone position, and exposure to cigarette smoke. The exact pathophysiology of SIDS remains unknown.
This document provides an overview of continuous positive airway pressure (CPAP) therapy for newborns, including:
- CPAP is a noninvasive respiratory support that applies positive pressure to prevent alveolar collapse. It is commonly used for preterm infants with respiratory distress.
- The presentation outlines what CPAP is, how it works, indications and contraindications for its use, guidelines for initiation and weaning, complications, and recent advancements.
- Proper use and monitoring of CPAP can help stabilize respiratory status for infants with conditions like respiratory distress syndrome, while avoiding complications such as nasal injury, gastric distention, or pneumothorax.
This document discusses fluid and electrolyte management in neonates. It outlines the physiological changes in neonates that impact fluid needs, including higher total body water and immature kidney function. It provides guidelines for calculating daily fluid requirements based on gestational age and weight. It describes the use of IV fluids for initial resuscitation and maintenance, adjusting for enteral feedings and weight changes. Conditions requiring IV fluids and formulas for replacing various fluid losses are also summarized.
Apnea of prematurity is common in preterm infants, especially those born before 28 weeks gestation or weighing less than 1800g. It is caused by immature development of the respiratory control centers in the brain. Treatment includes caffeine which reduces apnea by blocking adenosine receptors. Other supportive measures like positioning and CPAP may help as well. Apnea spells usually resolve by 36-37 weeks corrected gestational age. Before discharge, infants should have a period of at least 5-7 days without any recorded apnea events while off caffeine therapy.
1. Effective pediatric emergency teams have clear roles and responsibilities defined for team leaders and members. Team members should seek assistance early if a patient's condition deteriorates.
2. Team leaders should encourage knowledge sharing and suggest alternative interventions if needed. Team members should suggest changes confidently and question potential mistakes.
3. Teams should continuously evaluate patients after each intervention or if their condition changes, clearly communicating any significant changes.
The document describes 3 case scenarios involving newborn infants with respiratory issues. Case 1 involves a term newborn not crying after birth who is not responding to positive pressure ventilation. Case 2 involves a preterm infant admitted to the NICU with respiratory distress. Case 3 involves a preterm infant with symmetrical IUGR who develops repeated apnea while on CPAP support. The document asks what the problem is in each case. It then discusses troubleshooting positive pressure ventilation and various problems that can occur, such as air leaks, obstruction, equipment issues, and abnormal blood gases. Management strategies for different problems are provided.
This document discusses neonatal shock, including its pathophysiology, terminology, history of inotropic drugs, and clinical uses of various inotropic agents. It covers topics such as the unique features of the preterm cardiovascular system, oxygen delivery principles, shock etiologies like hypovolemia and myocardial dysfunction, and the mechanisms and receptors targeted by drugs like dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, and corticosteroids. Clinical scenarios where different agents may be beneficial or have limitations are also summarized.
This document discusses rational surfactant therapy. It begins by establishing that surfactant replacement therapy works based on multiple randomized controlled trials showing reductions in mortality, duration of ventilation and hospital stay. It describes the types of surfactants available and recommends natural surfactants. The document discusses the timing of surfactant replacement, benefits of multiple doses, and synergistic effects with antenatal steroids. Ventilatory management after surfactant including INSURE technique is covered, along with risks of the therapy.
The document discusses mechanical ventilation in neonates. It provides a brief history of mechanical ventilation and describes various modes of ventilation including positive pressure ventilation. Key aspects of intubation and ventilation such as indications, procedures, settings and complications are outlined. Lung physiology considerations specific to neonates such as compliance, resistance and time constant are also reviewed.
The document discusses the management of patent ductus arteriosus (PDA) in preterm infants. PDA occurs in 31% of very low birth weight infants and can be left untreated in some cases. Treatment may include conservative management, pharmacological closure with drugs like indomethacin or ibuprofen, or surgical ligation if drugs fail. Prophylactic drug treatment may help prevent complications in very preterm infants under 25 weeks gestation. The optimal management of PDA in infants under 800g is still debated, as untreated PDA carries risks but interventions also pose dangers.
This document provides guidelines and recommendations for CPAP therapy in preterm infants. It discusses when to initiate CPAP, essential aspects of CPAP such as settings and equipment, guidelines for weaning from CPAP based on gestational age and weight, important considerations for caring for infants on CPAP such as airway maintenance and positioning, criteria for monitoring infants on CPAP, potential complications and their management, and comparisons of masks versus prongs for CPAP delivery. Overall it aims to outline best practices for initiating, maintaining, weaning from, and caring for preterm infants receiving CPAP therapy.
Niv current trends karthik nagesh,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of various modes of non-invasive ventilation that can be used to support respiration in neonates, including advantages and disadvantages. It discusses nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), high flow nasal cannula (HFNC) therapy, nasal high frequency oscillatory ventilation (nHFOV), and neurally adjusted ventilatory assist (NAVA). The document summarizes the physiological rationale and evidence from studies comparing the different non-invasive modalities. It provides guidance on clinical situations where each mode may be indicated. The overall focus is on using the least invasive respiratory support possible to minimize lung injury and risk of chronic lung disease in preterm neon
The document describes three case scenarios involving newborn infants with respiratory distress. The first case involves an infant born at 30 weeks gestation who developed respiratory distress soon after birth and was normothermic, euglycemic, and had good reflexes and activity. The second case involves an infant born at 31 weeks gestation who was started on oxygen and later developed progressive respiratory distress, with CPAP initiated after the Downe's score reached 5 at 3 hours of age. The third case involves an infant born at 30 weeks gestation who was initially put on CPAP but required increased settings and eventually surfactant and mechanical ventilation due to inability to maintain saturation on CPAP. The document seeks management recommendations for each case.
Apnea of prematurity is the most common respiratory problem in premature infants, prolonging hospitalization. It is defined as a cessation of breathing for 20 seconds or less if accompanied by bradycardia or cyanosis. Incidence and severity are inversely related to gestational age, with 50% of infants under 1500g requiring intervention. Proposed causes include immaturity of the respiratory center, decreased afferent input, abnormal reflexes, and hypoxemia. Treatment focuses on stimulation, treating underlying causes, methylxanthines to stimulate breathing, and CPAP for severe or refractory cases. Methylxanthines like caffeine are the first line treatment but CPAP may be used if apnea is not resolved
This presentation is all about how to run a high risk follow up clinic for newborns discharged from a level II/III newborn care unit. It has been prepared mainly based on NNF protocol & AIIMS protocol.
This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
This document provides an overview of newborn resuscitation by Dr. Lokanath Reddy from the Department of Paediatrics at Kasturba Medical College in Manipal, India. It covers the history and principles of newborn resuscitation, initial steps, positive pressure ventilation, intubation, medications, special considerations for preterm babies, and ethics. Causes of neonatal compromise are discussed. Guidelines for newborn resuscitation from various medical organizations over time are summarized.
hhhfnc 2019,karneocon,vijayapura - Dr Karthik Nageshkarthiknagesh
High Flow Nasal Canula (HFNC) therapy in Neonates - Applications discusses the use of HFNC therapy in neonates as an alternative to invasive ventilation and CPAP. It provides an overview of the evidence and clinical settings where HFNC is indicated. It describes how HFNC works and guidelines for its use. The document also discusses some of the problems with more invasive forms of ventilation and how HFNC aims to provide respiratory support in a less invasive manner.
1. The pediatric ECG document reviews cardiac physiology and ECG findings in children of different ages. It discusses how the size of the ventricles changes from birth through childhood and how this impacts ECG measurements.
2. Key aspects of the normal pediatric ECG are described, including typical heart rates, axis shifts, and "juvenile" T wave patterns. Common abnormalities seen in pediatric patients such as chamber enlargement, conduction abnormalities, and arrhythmias are also reviewed.
3. The document provides guidance on interpreting ECG findings and correlating them to possible diagnoses in children, taking into account how measurements may differ based on age. Examples of ECG strips are included to illustrate various normal and abnormal
CPAP therapy provides positive airway pressure throughout the respiratory cycle to help stabilize the lungs. It has various physiological effects like decreasing respiratory rate and increasing functional residual capacity. CPAP can be applied through nasal prongs, masks, or endotracheal tubes. It is commonly used to treat respiratory distress syndrome, meconium aspiration syndrome, and apnea of prematurity. Optimal CPAP levels depend on the underlying lung disease and physiology. CPAP is generally well-tolerated but high levels can cause side effects like air leaks or decreased cardiac output. Close monitoring is needed when applying and weaning infants from CPAP support.
This document discusses apnea in infants and sudden infant death syndrome (SIDS). It defines apnea, describes the different types (obstructive, central, mixed), and potential causes. It outlines the clinical presentation of apnea and treatment options, including caffeine/theophylline. Though apnea is more common in preterm infants, it does not increase the risk of SIDS. The prognosis is generally good unless apnea is severe and refractory to treatment. SIDS is defined as the sudden unexpected death of an infant under 1 year that remains unexplained after autopsy. Risk factors include prematurity, sleeping in the prone position, and exposure to cigarette smoke. The exact pathophysiology of SIDS remains unknown.
This document provides an overview of continuous positive airway pressure (CPAP) therapy for newborns, including:
- CPAP is a noninvasive respiratory support that applies positive pressure to prevent alveolar collapse. It is commonly used for preterm infants with respiratory distress.
- The presentation outlines what CPAP is, how it works, indications and contraindications for its use, guidelines for initiation and weaning, complications, and recent advancements.
- Proper use and monitoring of CPAP can help stabilize respiratory status for infants with conditions like respiratory distress syndrome, while avoiding complications such as nasal injury, gastric distention, or pneumothorax.
This document discusses fluid and electrolyte management in neonates. It outlines the physiological changes in neonates that impact fluid needs, including higher total body water and immature kidney function. It provides guidelines for calculating daily fluid requirements based on gestational age and weight. It describes the use of IV fluids for initial resuscitation and maintenance, adjusting for enteral feedings and weight changes. Conditions requiring IV fluids and formulas for replacing various fluid losses are also summarized.
Apnea of prematurity is common in preterm infants, especially those born before 28 weeks gestation or weighing less than 1800g. It is caused by immature development of the respiratory control centers in the brain. Treatment includes caffeine which reduces apnea by blocking adenosine receptors. Other supportive measures like positioning and CPAP may help as well. Apnea spells usually resolve by 36-37 weeks corrected gestational age. Before discharge, infants should have a period of at least 5-7 days without any recorded apnea events while off caffeine therapy.
1. Effective pediatric emergency teams have clear roles and responsibilities defined for team leaders and members. Team members should seek assistance early if a patient's condition deteriorates.
2. Team leaders should encourage knowledge sharing and suggest alternative interventions if needed. Team members should suggest changes confidently and question potential mistakes.
3. Teams should continuously evaluate patients after each intervention or if their condition changes, clearly communicating any significant changes.
The document describes 3 case scenarios involving newborn infants with respiratory issues. Case 1 involves a term newborn not crying after birth who is not responding to positive pressure ventilation. Case 2 involves a preterm infant admitted to the NICU with respiratory distress. Case 3 involves a preterm infant with symmetrical IUGR who develops repeated apnea while on CPAP support. The document asks what the problem is in each case. It then discusses troubleshooting positive pressure ventilation and various problems that can occur, such as air leaks, obstruction, equipment issues, and abnormal blood gases. Management strategies for different problems are provided.
This document discusses neonatal shock, including its pathophysiology, terminology, history of inotropic drugs, and clinical uses of various inotropic agents. It covers topics such as the unique features of the preterm cardiovascular system, oxygen delivery principles, shock etiologies like hypovolemia and myocardial dysfunction, and the mechanisms and receptors targeted by drugs like dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, and corticosteroids. Clinical scenarios where different agents may be beneficial or have limitations are also summarized.
This document discusses rational surfactant therapy. It begins by establishing that surfactant replacement therapy works based on multiple randomized controlled trials showing reductions in mortality, duration of ventilation and hospital stay. It describes the types of surfactants available and recommends natural surfactants. The document discusses the timing of surfactant replacement, benefits of multiple doses, and synergistic effects with antenatal steroids. Ventilatory management after surfactant including INSURE technique is covered, along with risks of the therapy.
The document discusses mechanical ventilation in neonates. It provides a brief history of mechanical ventilation and describes various modes of ventilation including positive pressure ventilation. Key aspects of intubation and ventilation such as indications, procedures, settings and complications are outlined. Lung physiology considerations specific to neonates such as compliance, resistance and time constant are also reviewed.
The document discusses the management of patent ductus arteriosus (PDA) in preterm infants. PDA occurs in 31% of very low birth weight infants and can be left untreated in some cases. Treatment may include conservative management, pharmacological closure with drugs like indomethacin or ibuprofen, or surgical ligation if drugs fail. Prophylactic drug treatment may help prevent complications in very preterm infants under 25 weeks gestation. The optimal management of PDA in infants under 800g is still debated, as untreated PDA carries risks but interventions also pose dangers.
This document provides guidelines and recommendations for CPAP therapy in preterm infants. It discusses when to initiate CPAP, essential aspects of CPAP such as settings and equipment, guidelines for weaning from CPAP based on gestational age and weight, important considerations for caring for infants on CPAP such as airway maintenance and positioning, criteria for monitoring infants on CPAP, potential complications and their management, and comparisons of masks versus prongs for CPAP delivery. Overall it aims to outline best practices for initiating, maintaining, weaning from, and caring for preterm infants receiving CPAP therapy.
Niv current trends karthik nagesh,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of various modes of non-invasive ventilation that can be used to support respiration in neonates, including advantages and disadvantages. It discusses nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), high flow nasal cannula (HFNC) therapy, nasal high frequency oscillatory ventilation (nHFOV), and neurally adjusted ventilatory assist (NAVA). The document summarizes the physiological rationale and evidence from studies comparing the different non-invasive modalities. It provides guidance on clinical situations where each mode may be indicated. The overall focus is on using the least invasive respiratory support possible to minimize lung injury and risk of chronic lung disease in preterm neon
CPAP provides continuous positive airway pressure throughout the respiratory cycle to keep alveoli open and increase functional residual capacity in the lungs, improving gas exchange. It has a long history dating back to the 1970s and is commonly used for conditions that decrease functional residual capacity like RDS, apnea of prematurity, and BPD. CPAP is administered non-invasively via the nasal route using prongs, masks, or cannulae attached to a flow generator. It has physiological benefits like improved oxygenation and ventilation. Complications can include pneumothorax, nasal trauma, and gastric distension which are generally preventable with proper application and monitoring.
This document discusses various methods for delivering continuous positive airway pressure (CPAP) to neonates, including underwater bubble CPAP, variable flow nasal prongs, and newer technologies like SiPAP and Vapotherm. It notes that while different CPAP methods aim to improve outcomes, more clinical data is still needed to determine their safety and effectiveness compared to conventional CPAP. The document also advocates for renewed use of transcutaneous CO2 monitoring to help guide ventilation and avoid potentially harmful swings in blood gas levels.
1. Bilevel positive airway pressure (BPAP) delivers two levels of positive airway pressure - a higher pressure during inspiration and a lower pressure during expiration - to reduce work of breathing and improve oxygenation.
2. BPAP is effective for acute exacerbations of COPD and cardiogenic pulmonary edema by reducing mortality, need for intubation, and treatment failure compared to standard care.
3. For pneumonia, outcomes are worse with post-obstructive pneumonia, pleural effusions, hypoxic hypercapnic respiratory failure with effusions, and over 24 hours on BPAP therapy.
The document describes a case of a preterm infant born at 33 weeks gestation with low birth weight and respiratory distress. It then provides information on assessing and managing respiratory distress in newborns, including different scoring systems, delivery room management for preterm infants, and various modalities of non-invasive respiratory support such as nasal prongs, nasal CPAP, and high-flow nasal cannula. Key points discussed include initiating CPAP early for signs of respiratory distress and adjusting settings based on patient response and blood gas values.
This document discusses noninvasive ventilation techniques for neonates. It provides background on the increasing use of nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) as alternatives to invasive ventilation. The document describes various noninvasive ventilation methods including NCPAP, bi-level NCPAP, NIPPV, high flow nasal cannula (HFNC) and their physiological effects and clinical indications. Evidence is presented that both NIPPV and HFNC are effective for treating respiratory distress syndrome and hypoxic respiratory failure in preterm infants and that HFNC has similar outcomes to NCPAP for apnea of prematurity. The document concludes that NIPPV and HFNC reduce the risk
Bubble CPAP is an inexpensive respiratory support method for preterm newborns with respiratory distress syndrome. A study was conducted of 72 preterm newborns within 6 hours of birth who were randomized to receive either bubble CPAP or conventional oxygen therapy. Data on maturity, weight, presentation time, respiratory distress scores, duration of bubble CPAP, treatment failure, recurrent apnea, and survival rates were collected. The aim was to study the effectiveness of bubble CPAP for respiratory distress syndrome in preterm newborns.
Respiratory distress is common in preterm infants and can have serious consequences. It is defined as the presence of tachypnea, retractions, or grunting. Common causes include respiratory distress syndrome (RDS) due to surfactant deficiency. Assessment involves evaluating respiratory rate, work of breathing, oxygen needs and chest x-ray findings. Management consists of supportive care including oxygen supplementation, monitoring, antibiotics if indicated. Surfactant replacement therapy improves outcomes in RDS but can increase risk of apnea. Non-invasive respiratory support with CPAP is preferred over mechanical ventilation when possible.
This document provides an overview of non-invasive ventilation (NIV), including its definition, historical background, mechanisms of action, indications and contraindications, different modes (CPAP vs BiPAP), and evidence supporting its use. Key points include that NIV avoids intubation and its complications, evidence shows benefits for COPD exacerbations and cardiogenic pulmonary edema, and both CPAP and BiPAP can effectively treat acute cardiogenic pulmonary edema with no differences in patient outcomes.
Final newer modes and facts niv chandanChandan Sheet
THIS IS THE BASIC POINTS REGARDING NIV, THIS IS COMPILED AND ARRANGED FROM DIFFERENT BOOKS, JOURNALS AND PPTs.
The author is grateful to the teachers and authors of pulmonology and critical care.
This document discusses the use of noninvasive ventilation (NIV) for patients with COVID-19-associated acute hypoxemic respiratory failure (AHRF). It finds that the majority of COVID-19 patients treated with continuous positive airway pressure (CPAP) recovered from moderate-to-severe AHRF. For select patients, NIV may prevent intubation and invasive ventilation. However, patient selection is important and NIV may delay intubation in some cases. Close monitoring is needed to identify patients who require intubation.
This document discusses ventilator settings and CPAP. It provides an overview of basics of ventilators and ventilator settings. CPAP is described as preventing alveolar collapse, stabilizing the chest wall, and splinting the airway open. Different types of CPAP generators and components are outlined. Bubble CPAP is discussed as a simple and cost effective method. Advantages, initiation, monitoring and complications of CPAP are summarized. Factors in determining ventilator settings and their effects are also reviewed.
Non Invasive Ventilation in Children (NIV-C) provides respiratory support without invasive intubation. It assists in airway distension and oxygenation at the alveolar level, reducing respiratory effort. NIV-C improves outcomes and decreases intubation needs in acute settings. Proper patient selection and interface are important. NIV includes CPAP and BiPAP. CPAP provides constant pressure while BiPAP uses two pressure levels. Close monitoring is needed initially to assess response and potential failure requiring intubation. NIV-C benefits include avoiding intubation risks while allowing communication. Proper technique and settings are essential for success.
Lung protective strategies,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of advances in neonatal respiratory care from the 1970s to present day. It discusses the evolution of ventilatory care including the introduction of surfactant replacement therapy in the 1980s, high frequency oscillatory ventilation and nitric oxide therapy in the 1990s, and the increased use of non-invasive respiratory support methods like nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation, and high flow nasal cannula in the 2000s and beyond. The principles of care for extremely low birth weight infants in the first week of life are also outlined, focusing on ventilation strategies to minimize lung injury and optimize outcomes.
This document discusses non-invasive ventilation (NIV) in neonates. It begins by defining NIV and describing the different modes including nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP). It reviews the evidence that NIPPV compared to NCPAP reduces extubation failure rates, failure rates as a primary respiratory mode, and mortality/bronchopulmonary dysplasia. The document provides guidelines for using NIPPV as a primary respiratory mode in preterm infants.
Management of RDS, by Muhammad Ezzat Abdel-Shafy MB.BCh, M.Sc Pediatrics Neon...mohamed osama hussein
This document outlines guidelines for the management of respiratory distress syndrome (RDS) in preterm infants. It discusses prenatal care including corticosteroid administration, delivery room stabilization using continuous positive airway pressure (CPAP), surfactant therapy administered either prophylactically or as a rescue treatment, oxygen supplementation aiming for saturations between 90-94%, use of non-invasive respiratory support including CPAP and nasal intermittent positive pressure ventilation (NIPPV), supportive care including temperature and fluid management, and monitoring of blood pressure and perfusion. The document emphasizes early initiation of CPAP, selective surfactant administration when needed, and avoidance of mechanical ventilation where possible.
CPAPs can provide benefits for premature infants by maintaining positive airway pressure and oxygen levels. The constant pressure helps strengthen weak lungs and reduces the workload of breathing. However, high CPAP pressure can also have negative effects by reducing cardiac output and blood pressure. Therefore, using the appropriate level of pressure is important to support lung development without compromising cardiovascular function.
neuromonitoring of a newborn from common nervous system disease perspectives ...Dr. Habibur Rahim
This document summarizes key points about monitoring the nervous system in newborns. It discusses common neurological conditions seen in newborns such as perinatal asphyxia, intraventricular hemorrhage, neonatal stroke, meningitis, and TORCHS infections. For each condition, it outlines the location of injury, pathophysiology, clinical features, monitoring in the NICU, diagnostic testing, potential improvements or deteriorations, and complications. Imaging findings and grading scales for conditions like IVH are also presented.
basics of mechanical ventilator Dr Asaduzzaman.pptxDr. Habibur Rahim
Mechanical ventilation is an important life-saving intervention for extremely premature and sick newborns. While it supports oxygenation and carbon dioxide removal, it can also cause lung injury if not optimized. The document discusses the physiology of ventilation, components of mechanical ventilators like pressures and volumes, basic ventilation modes, and pulmonary graphics. Modes like volume guarantee aim to balance supporting gas exchange while limiting volumes and pressures. Understanding ventilation principles, ventilator operations, and individualizing strategies are important for achieving optimal outcomes for mechanically ventilated newborns.
approach to Rh Isoimmunization Maternal and neonatal aspects | Dr Habibur RahimDr. Habibur Rahim
This document summarizes the approach and management of a baby born to a Rh-negative mother. The baby presented with respiratory distress and signs of Rh isoimmunization. Key points include:
1) The mother's anti-D titer was 1:64 and Doppler ultrasound revealed increased blood flow, indicating Rh isoimmunization.
2) The baby received an exchange transfusion due to signs of hemolysis and hyperbilirubinemia.
3) With oxygen support and treatment, the baby's respiratory distress resolved within 6 hours and the baby improved after exchange transfusion.
Short bowel syndrome (SBS) occurs when extensive segments of the small intestine are resected, severely compromising absorptive capacity. It is a leading cause of intestinal failure in infants, with an incidence of 0.1-0.5% among live births and ICU admissions. The minimal length of small intestine needed to survive is 15-38 cm, though adaptation allows survival with even shorter lengths. Management involves total parenteral nutrition, optimizing enteral nutrition, and treating complications until the remnant intestine sufficiently adapts through processes like increased blood flow and growth. With current treatment, 80% of infants with SBS achieve full enteral nutrition within a year.
Approach to Baby of perinatal asphyxia | Dr Sonia Akter | Dr Habibur RahimDr. Habibur Rahim
This document discusses the management of a baby with perinatal asphyxia who also has issues of infant of diabetic mother, hypocalcemia, hypomagnesemia, and acute kidney injury. It provides background on the prevalence and risks of perinatal asphyxia. It also outlines the principles of management, which include restoration of blood flow, identification and treatment of multiorgan dysfunction, and seizure management. Therapeutic hypothermia and magnesium sulfate for fetal neuroprotection are discussed as standard or emerging treatments.
Seminar on critical Congenital heart disease Dr Habibur Rahim | Dr Faria YasminDr. Habibur Rahim
This document discusses the management of critical congenital heart disease in newborns. It describes how prostaglandin E1 (PGE1) is used to maintain ductal patency until definitive treatment. PGE1 is started as a continuous IV infusion at a low dose and titrated to safely establish an open ductus arteriosus. This improves oxygen saturation while definitive diagnosis and treatment are determined. Potential side effects include apnea, hypotension, and hyperthermia, requiring close monitoring during PGE1 infusion. PGE1 therapy is currently standard care for ductal-dependent congenital heart defects until palliative or corrective surgery can be performed.
Seminar on pulmonary hemorrhage in newborn by Dr. Habib, Dr. AshfaqDr. Habibur Rahim
Pulmonary hemorrhage is bleeding into the lungs that commonly affects premature infants. It presents with bloody secretions from the endotracheal tube and causes rapid clinical deterioration. Risk factors include prematurity, respiratory problems, sepsis, and mechanical ventilation. The pathophysiology involves stress on capillaries from transmural pressure, alveolar surface tension, and lung inflation. Management focuses on supportive care like ventilation, volume expansion, and transfusions to improve oxygenation and stop the bleeding. Prognosis depends on the severity and underlying causes, with mortality up to 50% in very premature infants.
- The patient is a 21-day-old male born prematurely at 30 weeks gestation with a birth weight of 1230g.
- He has a history of respiratory distress at birth and was treated for late-onset neonatal sepsis on days 5 and 16 of life.
- He is now presenting with signs of respiratory distress and sepsis including decreased activity, tachypnea, and desaturation. Laboratory results show thrombocytopenia and elevated inflammatory markers.
This document presents two case scenarios for discussion at a seminar on acute kidney injury in newborns. The first case involves a preterm, low birth weight baby with late onset sepsis who develops increased serum creatinine and decreased urine output after being treated with antibiotics. The second case involves a preterm baby with bilateral hydroureteronephrosis who develops oliguria, rising serum creatinine, and hypertension despite treatment. The document asks how each baby would be diagnosed and managed.
(1) Atypical genitalia in a genetic female with clitoromegaly and labial fusion, indicating virilization;
(2) Hyperpigmentation around the nipple and genitalia;
(3) Biochemical findings of elevated 17-OHP, ACTH and DHEA with low cortisol, consistent with 21-hydroxylase deficiency;
(4) Hyponatremia and hyperkalemia, suggestive of salt wasting form of CAH.
The child
This document provides information about evaluating a neonate presenting with cholestatic jaundice. It discusses performing a history and physical exam to identify potential etiologies. Key lab investigations are outlined to establish cholestasis and severity of liver injury. Imaging studies like ultrasound and hepatobiliary scintigraphy can help differentiate between extrahepatic and intrahepatic causes. The document reviews various etiologies of neonatal cholestasis including biliary atresia, idiopathic neonatal hepatitis, choledochal cyst, galactosemia, and TPN-related cholestasis. Timely evaluation is important to diagnose treatable conditions and identify those requiring surgical intervention.
- COVID-19 generally causes mild disease in children, but a small proportion can develop severe disease requiring ICU care.
- Symptoms in children are usually fever, cough, sore throat and some may experience diarrhea or vomiting.
- Investigations show lymphopenia and elevated inflammatory markers. Chest imaging may show patchy infiltrates or ground glass opacities.
- Management involves isolation and supportive care. Severe cases are treated in hospitals. Most children recover well but underlying conditions increase risk of severe disease.
The document summarizes the types, causes, pathophysiology, stages, and management of shock in children. It discusses the five major types of shock - hypovolemic, cardiogenic, obstructive, distributive, and septic shock - and their specific causes, pathophysiology, and treatment approaches. General management of shock includes fluid resuscitation, monitoring, laboratory studies, and medication therapy tailored to the underlying shock type. The document provides detailed guidelines on the evaluation and treatment of each shock type.
Management of shock involves positioning, airway support, vascular access, fluid resuscitation, monitoring, and medication therapy. The type of shock determines specific treatment, which may include fluid boluses, vasoactive drugs, and treating the underlying cause. Septic shock, the most common distributive shock, results from infection and involves a complex inflammatory response. Treatment focuses on antibiotics, fluids, and vasopressors like dopamine or norepinephrine to support blood pressure. The goal is to identify and treat shock early before organ dysfunction occurs.
This document provides information about macrophage activation syndrome (MAS) and hemophagocytic lymphohistiocytosis (HLH). MAS is a severe inflammatory condition caused by excessive activation of macrophages and T cells. It can occur secondary to conditions like systemic juvenile idiopathic arthritis. The document discusses the pathogenesis, clinical features, diagnostic criteria, investigations and treatment of MAS. It emphasizes the importance of promptly recognizing and treating MAS as it can be life-threatening.
This document provides an overview of tetralogy of Fallot (TOF), one of the most common cyanotic congenital heart diseases. It discusses the history, epidemiology, pathophysiology, clinical presentation, investigations, management, and prognosis of TOF. Key points include: TOF is characterized by pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Clinical features include cyanosis, clubbing, and systolic murmur. Investigations include CXR, ECG, echocardiogram and cardiac catheterization. Management involves medical treatment of spells, palliative shunt procedures, and complete repair surgery. Long-term prognosis depends on severity of pulmonary stenosis and associated anomalies,
This document provides information about atrial septal defects (ASD). It discusses the different types of ASDs including ostium secundum, ostium primum, sinus venosus, and coronary sinus defects. It covers the pathophysiology, clinical presentation, investigations including echocardiography and ECG findings, and management including device closure or surgery. Long term outcomes are also summarized such as the potential for spontaneous closure in small defects or complications in adults if left untreated, including congestive heart failure, pulmonary hypertension, and atrial arrhythmias.
A 9 month old girl presented with fever and vomiting for 3 days. She experienced a seizure before arriving at the hospital. On examination, she was febrile, drowsy, irritable, and had a bulging fontanel. Her throat was slightly inflamed. A lumbar puncture showed turbid CSF with a high white blood cell count, indicating bacterial meningitis. Further tests are needed to identify the specific bacteria causing the infection.
A seminar on urinary tract infections (UTIs) was presented. UTIs are common in children and can lead to complications if not treated properly. The presentation covered the definition, causes, risk factors, clinical presentation, investigations, treatment, and follow-up management of UTIs in children of different ages. Proper diagnosis and treatment of UTIs as well as preventing recurrence are important to avoid long-term issues like renal scarring and kidney damage.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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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
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
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.
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’).
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
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.
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.
29.
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
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
36.
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
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
70.
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%
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.
82.
83.
84.
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.