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CPAP – A “GENTLE” VENTILATION

CPAP – A “GENTLE” VENTILATION. DR ASHOK MODI MD, DNB, MRCP(UK) CONSULTANT NEONATAL INTENSIVIST Bhagirathi Neotia Woman & Child Care Centre. CONTENTS. Introduction Historical aspects How it works Methods Indications Weaning Adverse effects. Introduction.

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CPAP – A “GENTLE” VENTILATION

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  1. CPAP – A “GENTLE” VENTILATION DR ASHOK MODI MD, DNB, MRCP(UK) CONSULTANT NEONATAL INTENSIVIST Bhagirathi Neotia Woman & Child Care Centre

  2. CONTENTS • Introduction • Historical aspects • How it works • Methods • Indications • Weaning • Adverse effects

  3. Introduction • Respiratory distress in a just born baby- bad news! • For doctors – Inconvenience, complications(BPD) • More so for family – death, handicap, cost • Solution – CPAP • Doctors – convenient, less likely to go wrong • Family – baby saved, low cost • Do I need to tell more? • Continuous distending pressure to upper & lower airways, spontaneously breathing, throughout

  4. What is CPAP ? A technique of airway Management in which :- 1. Positive intrapulmonary pressure is applied artificially to the airways , whereby Distending Pressure is created in the Alveoli 2. Spontaneously breathing baby 3. Throughout the respiratory cycle

  5. Historical aspects • Harrison – 1st increased alveolar pressure during expiration in RDS; Abolition of the grunt in RDS – deterioration • Gregory et al(1971) – used CPAP 1st in spontaneously breathing neonate in RDS • Last 3 decades – long way to newer devices with better knowledge of physiology & bio-physics

  6. What does it do? • Prevents alveolar atelectasis, enhances & maintains FRC • Decreases total airway resistance • Regularises breathing pattern • Improvement in surfactant metabolism • Splints chest wall, airways & Pharynx • Reduces work of breathing

  7. What does it do? • Results in reopening of collapsed/unstable alveoli - • Increased surface area for gas exchange • Preserves surfactant esp if applied early • Prevents Intrapulmonary shunting • Net result improved oxygenation & ventilation

  8. How to deliver CPAP • Delivery of continuous positive airway pressure requires 3 components – 1. Flow circuit(warm & humidified) 2. An airway interface 3. A positive pressure system

  9. Airway Interface • Single nasal prongs • Binasal prongs(Short & Long) • Nasopharyngeal prongs • Endotracheal tube • Head boxes, nasal cannulae, face masks • Short binasal prongs most effective, least invasive

  10. Positive pressure system • Fluid column(Bubble CPAP) • Resistance applied at the expiratory valve e.g Draeger / Ventilator • Pressure generation at nasal level • CPAP generation in the immediate vicinity of nasal airway by converting kinetic energy e.g Infant flow driver

  11. DEVICES • Infant Flow Driver –unique fluid mechanics(fluidic flip action) • Bubble CPAP – oscillatory vibrations • Infant Ventilator with CPAP mode • Which is the best?

  12. Optimal pressure • No compelling Data • Traditional 4 –6 cm of water • However some studies as high as 10 cm H2O • Tailored to baby’s needs • Increments by 1 cm of water • Guided by CXR

  13. INDICATIONS • Mild to moderate RDS • Apnoea of prematurity • After extubation • Alternative to mechanical ventilation ( INSURE) • Presence of poorly expanded or infiltrated lung fields on CXR • Tracheomalacia or abnormalities of lower airways

  14. CONTRA-INDICATIONS • Definite need for intubation & Ventilation • Upper airway anomaly e.g choanal atresia, cleft lip & palate, TOF • Cardiovascular instability & impending arrest • Unstable respiratory drive • Untreated CDH • When CPAP is failing • Bronchiolitis

  15. Monitoring & Care • Minimal handling/Sedation • Nasal prongs of right size in place(FIXATION) • Orogastric tube • Care of the nares • Change of posture • Vitals & Continuous pulse oximetry • Blood gas, haematological, radiological & biochemical monitoring

  16. Is CPAP Helping? • Reduction in respiratory rate • Stabilization or reduction in Fio2 • Resolution of grunting • Reduction in degree of sternal & intercostal recession

  17. When is CPAP failing • Recurrent apnoeic attacks • Spontaneous episodes of desaturation • Increasing oxygen requirements • Worsening respiratory distress • Agitation not relieved by simple measures • Worsening blood gases

  18. WEANING • Once baby very stable with minimal respiratory distress, normal blood gas & improving CXR • Fio2 gradually weaned to 40 – 50% • Then pressure decreased in steps of 1 cm of water until 3 – 4 cm

  19. Not without its complications • Do not take CPAP lightly! • Pulmonary air leaks • Excessive pressure- compromise o2 • Abdominal distension • Hypotension • Local – excoriation, scarring, deformity

  20. Setting an simple CPAP

  21. To conclude • Gentle & poor man’s ventilation • Easy to set up & minimal training • Save babies with RDS in developing countries vs headbox O2 • Lots of unanswered questions yet – • Optimal device • Ideal pressure

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