CPAP MACHINES

Workbook on CPAP Science, Evidence & Practice

CPAP Machines
Dr . Ashok Deorari,
All India Institute of Medical Sciences, New Delhi

Continuous Positive Airway Pressure or CPAP is a modality of respiratory support

in which increased pulmonary pressure is provided artificially during the
expiratory phase of respiration in a spontaneously breathing neonate. Grunt in a
baby with respiratory distress reflects an attempt to generate CPAP to keep
alveoli open during expiration.
CPAP is distinct from Intermittent Positive Pressure Ventilation (IPPV) or
Intermittent Mandatory Ventilation (IMV) in which breathing is taken over by the
ventilator machine completely and an increase in pulmonary pressure occurs
during both inspiratory as well as expiratory phases.
CPAP results in increased functional residual capacity (FRC) thus decreasing
ventilation perfusion mismatch and better gas exchange. It results in splinting of
upper airway thus decreasing airway resistance. These physiological effects
result in decreased work of breathing and conservation of surfactant. However,
excessive amount of CPAP can result in pulmonary air leaks and increase in
pulmonary venous pressure. This can adversely affect the brain (increased risk
of IVH) and heart.
An ideal CPAP delivery system consists of:
· A continuous supply of warm, humidified, blended gases at a flow rate of
2-3 times the infants minute ventilation
· A device to connect the CPAP circuit to infant's airway
· Means of creating a positive pressure in the CPAP circuit. (Fig. 1)

O2 Pt. Delivery
HUMIDIFIER Pr.monitor

air BLENDER RESERVOIR Exp.

Figure 1: CPAP System

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CPAP delivery systems

1. Ventilator
Ventilator is the ideal system to provide CPAP, but is expensive. It has blender for
oxygen-air mixing, FiO2 dial, humidifier, safety feature and a system to warm the
gases. One simply has to switch over to CPAP mode and connect it to the baby.
2. CPAP system
CPAP system which delivers pressure and gases are available in Indian market. An
ideal system must have the following capabilities:
1. End expiratory pressure of 0-15 cm water.
2. Humidification of up to 100%
3. Gas flow 5-8 L/min
4. Warming of gases to 34-37ºC.
5. Blending of oxygen air mixture (FiO2 range of 0.21-1.0)
6. Display of FiO2
7. Safety device against excess pressure
8. Tubing made of medical grade material with low dead space
9. Patient outlet to fit on to standard nasal prong system
10. Sterilizability of tubing.
11. Low noise compressor
12. Capability to run continuously for days and weeks
13. Good aesthetics, easy caring
14. Easy maintenance
15. Reasonable cost
Unfortunately none of the CPAP machines recently marketed in India have the
above features.
3. Improvised system
Several books show a simple CPAP system using under-water system. In principle
this system is doable, albeit cumbersome. But, in India, where air-oxygen
blenders are not available, it has to be used only with 100% oxygen. This means
we will always deliver 100 percent oxygen with locally made CPAP which is not
rational. It is, therefore, not a good method to be used in practice.

Patient interfaces for providing CPAP

Nasal prongs
Nasopharyngeal prongs
Nasopharyngeal tube
Face masks

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Prerequisites for a good CPAP delivery system

· Flexible light weight tubing

· Ease of application and removal
· Low resistance
· Soft & relatively atraumatic
· Simple and easy to use
· Cost effective

Types of CPAP based on gas flow

CPAP is divided in to two types depending upon type of flow viz. continuous flow and
variable flow CPAP
(1) Continuous flow CPAP: In this type, a neonate is provided a continuous fixed
flow of gases irrespective of the phase of respiration. Ventilator derived CPAP,
conventional stand alone CPAP machines and Bubble or water-seal CPAP are perfect
prototypes.
Bubble CPAP: Was first described and used in Columbia University under the name of
Hudson CPAP in 1970s. In this, warm and humidified blended gas flows to the infant
via nasal prongs. The distal end of the expiratory tubing is immersed in sterile water
(addition of acetic acid makes the water bacteriostatic) to a specific depth to provide
the desired level of CPAP e.g. the tubing is immersed to a depth of 5.0 cm to provide
CPAP of 5.0cm H2O. Bubble CPAP with the combined effects of CPAP and pressure

Flow meter

Oxygen blender

Expiratory line
Inspiratory line
Manometer

Heated
Endotracheal
humidifier
tube
Bottle with sterile
Fig. : Bubble CPAP water

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oscillations from the bubbles provides a lung protective, safe and effective method of
respiratory support to spontaneously breathing neonates. Bubble CPAP effectively
maintains FRC. The bubbling is also associated with the pressure oscillations, which get
reverberated back into the infant's airway and may provide gas exchange through the
principle of facilitated diffusion. This physiologic effect of bubble CPAP may help
improve gas exchange and reduce the infant's work of breathing. Bubble CPAP may
reduce the need for intubation, mechanical ventilation and reduce the incidence of
chronic lung disease (CLD).
Hudson CPAP: Hudson prongs come in six different sizes for varied birth weight
groups with cap and patient circuits with heated humidified wires. The prongs are
applied using tegaderm and velcro ; stabilized usi ng safety pins on the woollen cap.
The expiratory limb dips in the water bottle; the water level is the cpap pressure in cms
of water.
(2) Variable/Dual flow CPAP
Variable flow CPAP generates CPAP at the airway proximal to the neonate's nares. It
uses Bernoulli effect via dual injector jets directed towards each nasal prong in order to
maintain constant pressure. If the neonate needs more inspiratory flow, the venturi
action of the injector jets entrains additional flow. Due to Coanda effect during
spontaneous expiratory effort there is fluidic flip which causes flow to flip around and to
leave the generator chamber via the expiratory limb. A residual gas pressure is
provided by the constant gas flow, which enables stable gas delivery at a desired
pressure during the entire respiratory cycle. The fluidic flip mechanism reduces the
work of breathing almost to one fourth of the continuous flow CPAP in which neonate
has to exhale against the full continuous flow of gas. It is also found that variable flow
maintains better uniform pressure level than continuous flow. Still, cost and free
availability are the limiting factors.
Coanda effect: This phenomenon is caused when an air stream passes by a wall and
turbulent gas flow causes an attachment of the stream to the wall. As gas travels faster
over a pocket formed by turbulent air, the air stream is "pulled" closer to the wall.
Basic components of variable flow CPAP are
1. Flow driver: Provides adequate flows of appropriately blended gases.
2. Humidifier
3. Flow generator
4. Patient interface
5. Circuit
6. Fixation appliance
Figure: Exhibiting Coanda effect (Showing Infant Flow generator with Fluidic
Flip effect)
Examples:
1. Infant flow system
2. Arabella

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3. SensorMedics CPAP generator-SIPAP
4. Medijet
All four generators work on same principle of fluidic flip, have subtle
differences
Medijet nCPAP Generator

Physical Valve CPAP Cylinder

Jet-injector Connector unit

Measuring
connector

Gas input connector Pushing Safety hole Nasal prong connector

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Table 2: Available CPAP machines in Indian market

S.No. Make Dealer Principals Cost

1. Indian CPAP Phoenix Medical Phoenix Medical Rs 40,000 to

Meditrin Meditrin 1,00,000/-
Zeal Medical System Zeal Medical System
Lectromedik Lectromedik
Shreeyash Shreeyash

2. Bubble CPAP Fisher & Paykel Fisher & Paykel Rs 1,60,000/-

Hudson Hudson

3. Dual Flow CPAP Rohanika Sensor medics, Rs 23,00,000/-

a. SIPAP Criticare India Pvt Ltd Viasys EME,
b. IFD Trivitron, Chennai UK
c. Arabella Pulmocare Consultants Trivitron
D. Medijet Phoenix Medical Medijet
Phoenix Medical

Table 3: Patient interfaces available for CPAP

S.No. Make Dealer & Address Cost

1. Argyle prongs SB Medicare Pvt Ltd Rs. 800/- available in

Mr JM Rishi three sizes <1 kg ;
Mb.: 9810117939 1-1.5 kg; > 1.5 kgs
[email protected]

2. Hudson prongs a. Telflex medicals pvt ltd Rs. 1500/- six sizes with
Blue Haven, N019, Harrington Road, cap and patient circuit
Chetpet, Chennai-6003031
Ph.: 919841722791/04428365040
Email: [email protected]
b. Hudson RCI
CNC Medical Devices,
262 Adi Mansion,
Dr Cawasji Hamusji Street,
Mumbai -400002
Mb 9820062869
Email [email protected]

3. Nasopharyngeal Vygon India Pvt Ltd Rs. 500 for the prongs
prongs B 17/ sector 34, Info city
Gurgaon-122001
0124-4002801/802
www.vygon.com

4. Fisher and Fisher and Paykel Nasal prongs Rs. 380

Paykel India Branch Office, 339/1,HIG, Nasal tubing Rs. 800
A sector, 2nd stage extension, Caps Rs. 500
Yelahanka New Town, Circuit Rs.2200
Bangalore, 560064
919849041888, 918042844000

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