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Optimize Initial Respiratory Support

Bubble CPAP vs. High Flow Nasal Cannula Gil Urquidez, RRT-NPS Supervisor, Respiratory Care Services Santa Clara Valley Medical Center. Optimize Initial Respiratory Support. Goal:

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Optimize Initial Respiratory Support

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  1. Bubble CPAP vs. High Flow Nasal CannulaGil Urquidez, RRT-NPSSupervisor, Respiratory Care Services Santa Clara Valley Medical Center

  2. OptimizeInitialRespiratorySupport • Goal: • To establish and maintain the VLBW infant’s respiratory efforts and functional residual capacity without injuring the lung (Vent Induced Lung Injury) from excessive use of positive pressure ventilation.

  3. Continuous Positive Airway Pressure Technique of applying a continuous distending pressure to the lungs in a spontaneous breathing infant. Usually< 10 cm of water pressure 5-10L humidified flow of blended air What is CPAP ?

  4. How does it Work ? • Distends the airway and alveoli • Maintains lung volume in expiration/FRC • Makes breathing easier • Improves gas exchange

  5. Philosophy of use • Patience • Permissive Hypercapnea • Non invasive application

  6. CPAP Beneficial effects immediatelyfollowing Resuscitation • Benefits • Decreased requirements for Intubation • Decreased requirement for high levels of inspired Oxygen • Decreased Mechanical Ventilation Length of Stay • Decreased need of Postnatal steroids • Compared to Historical controls P.Jegatheesan J of Perinatology 2006 26, 189 - 196

  7. CPQCC Recommendation… • Tool-Kit Best Practice #7 • Optimize Initial Respiratory Support • Early use of CPAP (within 60 seconds of life) • Avoid Intubation (if possible) • Avoid prophylactic use of Surfactant in the DR

  8. What Causes Chronic Lung Disease (CLD)?

  9. Summary of Current Causes of CLD/BPD in VLBW CAUSE EFFECT Barotrauma Volutrauma Atelectotrauma Developmentally Impaired Alveolarization and Vascularization Poor Nutrition Recurrent infections Pressure Volume Repeated popping open Less alveoli Not enough resources to grow Scarring and destruction

  10. Why Did VMC Switch to Bubble CPAP Therapy?

  11. Bubble Nasal CPAP • Cost Effectiveness • Less Invasive Than A Other Interfaces • To Improve Overall Outcomes • Columbia Medical Center’s Experience • CLD rates are the lowest in the country • Bubble CPAP is SOLE form of Nasal CPAP.

  12. Positive Outcomes Associated With The Change In Practice

  13. Benefits Associated With Change In Practice

  14. Improved Outcomes Associated With Change In Practice

  15. VLBW survival WITHOUT significant IVH • SCVMC NICU

  16. How do we create our own Bubble CPAP System? How do we do it? What equipment do we use? Where do we get it?

  17. Creating our Setup Where do we start?

  18. Creating our Setup What hat to use? Where do we get them?

  19. Creating our Setup • Preparing for the cannula

  20. Creating our Setup • Securing the cannula to the patient

  21. Creating our Setup • Chin straps

  22. Creating our Setup Water Bottles

  23. Creating our Setup Original Setup

  24. How can we improve it!

  25. Creating our Setup • Other options

  26. Creating our Setup Other Options

  27. Other Options Creating our Setup

  28. Previous System Creating our Setup

  29. Current Set Up

  30. New Circuit & Bubble Chamber

  31. Multiple Sizes for Prongs/Mask

  32. High Flow Nasal Cannula

  33. Definition • High Flow Nasal Cannula is defined as heated humidified gas delivered at flows greater than 1lpm. • VMC defines High Flow Nasal Cannula as heated humidified gas delivered at 2lpm.

  34. High Flow Nasal Cannula Set-Up

  35. Cochrane Collaborative Review of High Flow Nasal Cannula 2011 Issue 5 • There is insufficient evidence to establish the safety or efficacy of HFNC as a form of respiratory support in the preterm infant • When used following extubation there may be a higher reintubation rate compared to NCPAP • More trials are needed

  36. Early Weaning From NCPAP To HFNC Is Associated With Prolonged Oxygen Use • Randomized control trial • Clinically stable on < 30 % O2 for 24 hrs randomized to HFNC (2 L) or Stay on CPAP till go straight to room air. Hany ES Early Human Development 2011

  37. High Flow Nasal Cannula • PRO’s for HFNC Use • Ease of use • Improved feeding and tolerance • Easier nursing/patient handling • Decreased nasal septal trauma

  38. High Flow Nasal Cannula • CON’s for HFNC use • Limited data • Unmeasured PEEP • No alarms

  39. VMC’s Position on HFNC High Flow Nasal Cannula usage when: Patient fails multiple attempts off Bubble NCPAP Is still needing more than 2lpm flow

  40. Greg Is Not Happy with the Baby’s NCPAP Set Up

  41. What’s wrong with this set up?

  42. The Baby Is Agitated and Desating! What Can We Do To Fix This?

  43. Aaahhh….I feel much better!

  44. I Can See You!!!

  45. Greg’s NOW a Happy Nurse!!!

  46. A Happy Baby is a Happy Nurse And ULTIMATELY a HAPPY RT!!!

  47. MATCH the Definition on the RIGHT with the Therapy on the LEFT Conclusions Good • CPAP is • Bubble CPAP is • High Flow Nasal Cannula • Oxygen is a Drug • Needs Further Study  • Good • Use with caution • Great Great Needs Further Study Use with Caution

  48. Thank Yous!!! Craig Ivie, Director, Respiratory Care ServicesDr. Balaji Govindaswami, Director, NICUAll Associate AttendingsAll NICU StaffMy Respiratory Care Staff

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