Continuous Positive

Airway Pressure (CPAP)

Non Invasive Ventilation
Non invasive ventilation: providing respiratory support
without endotracheal intubation
Primary mode of respiratory support in preterm baby
Nasal continuous positive airway pressure (NCPAP)
the gold standard
Neonates pay heavy price for invasive ventilation
Risk of lung injury/BPD
Risk of infection
Cost involved
Ventilation strategies that reduce lung injury/BPD
Avoid mechanical ventilation( Level I/A)
Gentler ventilation/VG (Level III/C)
Use of Non-invasive ventilation ( Level III/C)
Nasal CPAP- the gold standard
Growing evidence of its safety and use
Large RCT- (COIN/SUPPORT) establishing its feasibility
even in the smallest babies
Observational studies ( Colombia experience)
Showing reduction in BPD rates
Non invasive ventilation
CPAP
Synchronized
NSIMV NSIPPV NPSV
NIPPV
Non Synchronized
NIMV NIPPV
Bi PAP
HFNC
DiBlasi, Resp Care 2011

Graphical presentation of the different pressure levels used
in non invasive ventilation and comparing it with normal
breathing
CPAP Mantra
Opens the lung at functional residual capacity (FRC)
Keeps it open by minimal constant pressure -least atelecto, baro
and volutrauma
Pulmonary arterial pressure are least hence less V/Q mismatch
less pressures required
No ET tubes- no biotrauma
Physiology of CPAP

Pulmonary
Splint open the airway thus reduces the resistance as well as
the incidence of obstructive apneas
Increases FRC and thoracic gas volume
Decreases V/Q mismatch
Splints upper airway airway resistance
Work of breathing
Collapsed alveoli in neonates due to lack of
surfactant and prematurity
CPAP added to collapsed alveoli splints it open to
create FRC and improve gas exchange and ventilation
and perfusion
Tidal volume, CO
2
washout

Conserves surfactant- better type II- pneumoyte function and
recycling of surfactant.
Stimulates J receptors by stretching the lung/pleaura and
providing positive feedback to respiratory center by Hering
Breuer reflex.
Increases PaO
2
, Decreases PaCO
2
lung compliance
Helps in recruiting previously collapsed alveoli and thus
increases the FRC of the lungs
Stabilizes the highly compliant chest wall of preterm infants
and helps in counteracting the paradoxical movements
Increases the mean airway pressure and improves the
ventilation-perfusion (V/Q) mismatch


Reduces right-to-left shunting
Conserves surfactant on the alveolar surface
Regularizes and slows the respiratory rate
Reduces the work of breathing

Indications of CPAP
Respiratory Distress Syndrome (RDS)
Apnea of Prematurity (AOP)
Transient tachypnea of newborn (TTNB)
Meconium aspiration syndrome (in isolated instances)
Atelectasis
Pulmonary edema
Pulmonary hemorrhage
Chronic pulmonary insufficiency of prematurity
Respiratory support following extubation
Tracheomalacia
Partial diaphragmatic paralysis.
Of these, CPAP has been extensively studied (and commonly
used) in the following three conditions:

1. Early management of RDS
2. Treatment of apnea of prematurity
3. Post-extubation management following mechanical
ventilation.
CPAP Delivery Systems
Continuous flow CPAP
Ventilator derived CPAP- variable resistance in a valve is
adjusted to provide resistance to flow.
Bubble CPAP or waterseal CPAP- gas flows to the neonates
nares and expiratory limp is immersed specific length to
produce the required pressure.
Ventilator derived CPAP

Bubble CPAP

CPAP delivered via Bubble CPAP System
Efficacy and safety of bubble CPAP in neonatal care in low and
middle income countries: a systematic review. Martin S, Duke T,
Davis P (August 2014)
3 studies- BCPAP vs oxygen therapy, 30%-50% reduction in
mechanical ventilation, Other 3 trials comparing bubble CPAP
with ventilator CPAP
Meta-analysis of CPAP failure in these same trials showed a
lower failure rate in the bubble CPAP groups (p <0.003)
There is evidence that bubble CPAP is safe and reduces the
need for mechanical ventilation. Further research into the
efficacy of bubble CPAP in low-income and middle-income
countries is needed.
Variable flow CPAP
Reduces work of breathing
Based on Bernouli effect, Venturi action and Coanda effect
(fluidic flip)
Infant floe driver
Arabella system
SensorMedics CPAP systems


Interfaces
Head box
Face mask
Nasal mask
Nasal prongs
Argyle
Hudson

Argyle
Hudson
Infant Flow driver
Cut down ETT
Duotube
Nasal mask
Different interfaces for CPAP delivery

Head caps, baby flow, nasal masks and nasal prongs

CPAP delivered via nasal prongs

CPAP delivered via nasal mask

CPAP delivered via Hudson prongs
CPAP delivered via Hudson prongs

CPAP delivered via infant flow driver
Endotracheal CPAP
Via endotracheal oro or naso-tracheal
Breathing through a straw
Increased work of breathing
All disadvantages of intubation
Cochrane review forbids use of ET CPAP for extubation
Parameters
Pressure
Start with 5 cmH
2
O in case of RDS or Pneumonia and a
pressure of 4 cmH
2
O if CPAP is for apnea managaemnet.
Pressure is adjusted to minimize chest retractions and to
observe 6 to 8 rib spaces on the chest x ray.
Flow
Flow is set minimal to produce a continuous bubbling in
bubble chamber. It does vary depending on the lung
disease, weight of the neonate, leak present from neonate
side. In most cases a flow of 5-6 LPM is sufficient and is
directly related to the minute ventilation of the neonate.


Inspired Oxygen
Start with 40%, after adjusting the pressure, titrate the O
2
to maintain SpO
2
between 92%-95%.
In absence of blender for adjusting FiO
2
mix air and oxygen
gas flows to get desired FiO
2
using the following formulae:-
Oxygen delivered = (1* Oxygen flow) + (0.21 * Air flow)
Total gas flow
Monitoring and Assessment
Vitals : heart rate, temperature, respiratory rate, blood
pressure and SpO
2
Assessment of circulation: capillary refill time, blood pressure,
urine output
Scoring of respiratory distress: Silverman score and Downes
score
Downes Score
Score 0 1 2
Respiration
<60 60-80 >80
Cyanosis
None in room
air
No cyanosis in 40% O
2
Requiring > 40% O
2
Retraction
None Mild Moderate to severe
Grunting
None Audible with
stethoscope
Audible without
stethoscope
Air entry
Good Decreased Barely audible
Silverman Anderson Score
CXR: starting of CPAP or 4 hrs later or when there is a clinical
deterioration
Blood gas: once/twice a day, clinical indication. Capillary gases
are preferred.
Neurological status: tone, activity and responsiveness
Abdominal distension: bowel sounds and gastric aspirates to
prevent CPAP belly. Timely recording of abdominal girth.

Monitoring
Ensure correct position and fixation of the interface
Clean the nostrils with saline drops, suction the secretions,
Prevent injury to the nasal septum by ensuring a gap between
the interface and columella.
Fill the humidification chamber and ensure that the gas
reaching the neonate should be at 37C and 100% relative
humidity.
Connecting CPAP

1
2
3

4
5
6
7
8 9

Avoid traction of weight of the circuit on the neonates head
and nose.
The immersion of the expiratory limb in bubble CPAP should
be recorded hourly.


Adequacy of CPAP
Comfortable
Minimal or no retractions
Normal CFT, BP
SpO
2
is 89% -94%
Blood gas : PaO
2
is 50-80mmHg, PCO
2
is 40-60 mmHg and pH
is 7.35 to 7.45.
Bubbling in the bubble chamber and also bubbling sounds on
auscultations of the chest.

Hazards, Adverse effects and
Complications of CPAP
Proper positioning of the interface is often a difficulty
Obstruction primarily due to mucus, secretions inspite of
optimum humidification
Local irritation to the nares and oral cavity.
Hyper expanded lungs, Tendency for air leaks
pulmonary vascular resistance (PVR)
Renal effects like reduced urine output (decrease in
glomerular filtration rate)
Increase in intracranial pressure
Gastric dilation and rupture (decrease in gastrointestinal
blood flow)
Nasal trauma mild or severe including nasal snubbing,
flaring of the nostrils and columella necrosis



The nasal septum is injured with nasal snubbing

The nasal septum is injured with nasal snubbing
Failure of CPAP
CPAP is failure when
FiO
2
>60%
PEEP > 7 cmH
2
O
Baby continuing to have retractions, grunting and recurrent
apnea on CPAP
SpO
2
<85% or PaO
2
>50mmHg and PaCO
2
>60 mmHg with
FiO
2
>60% and PEEP >7cmH
2
O
Before considering CPAP failure ensure:
Baby not fighting the interface
Interface is of correct size and in correct position
Humidification is adequate and no condensation in circuit
Adequate pressure and FiO
2
were delivered
Neck position, clear nostrils and airway
Weaning
Maintain proportionality of settings.
Wean pressure by 1cmH
2
O as the retractions reduce and
comfortability.
Titrate oxygen first 5 % decrements as SpO
2
maintain more
than 95%.
Apnea free intervals of 24-28hrs.
Clinical indication for CPAP is passive weaning criteria.
If tolerated well, with stable vitals and stable Downes score,
the periods of removal could be prolonged.
When the neonate is with CPAP of equal and lower than
5cmH
2
O and FiO
2
of 21%, CPAP could be removed and trial off
periods could be given.
After the removal of CPAP close monitoring of the neonate is
required, like frequent change in position, oral and nasal
suction. A Downes score should ne recorded to know the exact
respiratory status of the neonate.
If any sign of distress, eg like heart rate increases 10% more
than baseline consider connecting back to CPAP.
Take away points
The primary requirement of CPAP in a neonate is the presence of good
respiratory efforts
CPAP is contraindicated in neonates with poor respiratory efforts,
congenital diaphragmatic hernia, tracheoesophageal fistula, choanal
atresia, cleft palate, and in those with severe cardiovascular instability.
Always increase pressure before FiO
2
for better oxygenation.
Increase or decrease pressure to minimize chest retraction, maintain to
6-8 posterior rib spaces on the chest x-ray and to maintain
PaO
2
> 50mmHg
References
Goldsmith & Karotkin: Assisted Ventilation of the
Neonate, 4th edition
Workbook on CPAP, Science, Evidence and Practice, Learners
guide, The Department of Pediatrics, All India Institute of
Medical Sciences, New Delhi ;Post Graduate Institute of
Medical Education Research, Chandigarh ;Fernandez Hospital ,
Hyderabad