CPAP - INFLATION OF ATELECTATIC LUNG Dr. Rakesh kotha Associate professor of neonatology Niloufer hospital

VENTILATOR USUALLY DELIVERS INSPIRATION OR EXPIRATION PRINCIPLE NOSE =HUMIDIFIER LUNGS=VENTILATOR MORE INVASIVE TO MORE EFFECTIVE LESS INVASIVE

PEEP FRC < CV( neonates)

Where does CPAP stand? Ventilator NIPPV CPAP HHHFNC Low flow 02

does not require an ETT permits spontaneous breathing continuous pressure PEEP OBSERVE GRUNT FRC O2 ET

Types 1. Continuous flow CPAP – Bubble CPAP Ventilator CPAP 2. Variable flow CPAP Infant flow driver Pressure delivered at nose Expiration is passive

Any signs of significant respiratory distress Active <500gm Diseases with low functional residual capacity (FRC): SAS (APGAR) Indications

Respiratory Distress Syndrome (RDS) Transient Tachypnoea of the newborn (TTN) Post extubation Tracheomalacia Apnoea of prematurity Pulmonary oedema

PEEP= CDP facilitates gas exchange maintains functional residual capacity (gas for respiration) reduction of airway collapse by decreased airway resistance splinting of the pharyngeal airway to avoid obstruction HB reflex

PEEP principles keeping surfactant on alveolar surface and reduction of alveolar oedema reduced work of breathing (Half dilated) improvement in ventilation-perfusion ratio and decreased intrapulmonary shunting OPEN LUNG CONCEPT(50%)

P=2T/r Recruitment

Contraindications: Upper airway abnormalities - choanal atresia, cleft palate, unrepaired trachea-oesophageal fistula,MAS Congenital Diaphragmatic hernia pre surgical repair

Attach only after optimum heating of humidifier NOSE

Circuit 37 C 100 % RH AA P? >8L

A34C 70 RH to 37 C 100 RH Adequate? AH RH

MORE BUBBLES ?(5 lit enough) CO 2 elimination &Surfactant secretion How to test CPAP delivering adequately ( ex:prongs will touch the nose) Humidification adequate ? (Water column will increase) Which type of water Open mouth

Ventilator CPAP Same circuit CPAP Hudson prongs/ mask (SIZE OF NARES AND DISTANCE) PIP? EXPIRATION =Passive?

Initiation CPAP 5cm Flow 5 L Fio2 50% (30%) spo % Increase : 8cm H20 Cease : 4 cm h20 Fio2<30% Comfortable 5/5/5/5

Escalation And Weaning And Titration Rule of Propotion PEEP 5 FiO2 50% Retractions=PEEP

Ten questions 1. What pressures to use ? 5 or 6 cm 2. Upto what Fio2 can I keep on CPAP ? 50 /60% 3. At what Flow ? 5-8 L/min 4. How much bubbling? Just enough(TURBULENT) 5. Should I worry about pneumothorax ? Yes

6. Should I do ABG daily ? No 7. What pco2 can I accept ? 50 mm Hg 8. When to wean ? Comfortable, Fio2<30%, PEEP 4/5, ABG normal 9. Can I feed, KMC ? Yes. Yes Yes 10. Is nursing care important ??

Interface Binasal prongs ETT ( Nasphra yngeal ) MaskChinstrap pacifier

Nose Injury,Distance,should not dilate

Evidence CPAP with early rescue surfactant Less intubation Less surfactant Less mortality COIN/CURPAP/ SUPPORT /VON DRM

CPAP does not maintain oxygen saturation > 90% SAS score > 6 despite being on 50% oxygen and PEEP of 6 cm H2O if a neonate develops > 2 episodes of apnoea needing stimulation or positive pressure ventilation in 24 h Failure

Flow has to be altered to ensure proper bubbling It is difficult to detect high flow which can lead to over distension of the lungs Ossillations?