Continuous Positive Airway Pressure in Neonates.pdf

CPAP in Neonates

1. WELCOME TO THE SEMINAR
Dr. PoonamBodh
Dr. Nadia Hossain
Resident, year-3
Department of Neonatology
BSMMU

2. Scenario--1
B/o Ayesha, PT(28wk) extremely low birth weight(900g)
admitted into NICU due to prematurity and low birth weight.
On day-3 baby developed repeated apnea, in between attack
baby had spontaneous respirations and reflex activities were
good.Duringattack baby was euglycemic, well-perfused,
normothermic

3. S/oLabonno,PT(30wks)VLBW(1250gm)admittedintoNICUwith
thecomplaintsofbornbeforedate,LBW,respiratorydistresssoon
afterbirth.BabywasonMVforlast5days.accordingtoclinical
improvementaswellasbloodgasmonitoring,decidedtoweanfrom
MV.
2

4. B/O Tania, term (34+wk) LBW (1600g) admitted into NICU with
the complaints of respiratory distress soon after birth in the
form of tachypnoea, upper and severe chest retraction,
grunting. Mother had no history of taking antenatal
corticosteroids.
3

5. What will be our initial management

6. CPAP SUPPORT

7. Headlines
Definition
History
Types of CPAP
Advantages and disadvantages
Devices used for CPAP delivery
How CPAP works and effects
Indications
contraindications

8. Essentials of CPAP
Care of new born on CPAP
How to monitor while on CPAP?
Complication
Procedures of removal of CPAP
CPAP failure
Take home message

9. CPAP

10. Definition
CPAPrefers to the application of positive pressure to the
airway of a spontaneously breathing infant through out the
respiratory cycle.

11. HISTORY
The first clinical use of CPAP was reported by Gregory et al in a landmark
report in 1971.
After the initial enthusiasm, it gradually fell out of favor in 1980s because of
the advent of newer modes of ventilation.
However, reports of significantly lower incidence of chronic lung
disease (CLD) from Columbia University unit that used more CPAP as
compared to other North American Centers have led to resurgence of
interest in CPAP over the past 15 years.

12. Types of CPAP:

14. Advantages and disadvantages of different
CPAP

15. Devices Advantages Disadvantages
Conventional ventilatorderived
CPAP
•Noneed of a separate
equipments
•Can be easily switched over to
MV if CPAP fails
•Expensive
•Presence of high leak
•Difficult to know set flow is
sufficient or not
Stand-alone CPAP machines •Economical
•Usefulfor small hospitals
•Can have bubble CPAP option
•Most of them do not have
proper blenders and /or
pressuremanometer
Bubble CPAP •Simple and inexpensive
•Oscillations produced by
continuous bubbling contribute
gas exchange
•Flow has to be altered to
ensure proper bubbling
•It is difficult to detect high flow
which lead to over-distension of
the lung.

16. Devices used for CPAP delivery
Various devices used for CPAP delivery include:
1. Nasal prongs (single/double or binasal)
2. Long (or) nasopharyngeal prongs
3. Nasal cannula
4. Nasal masks.
Face mask, endotracheal, and head box are no longer used for CPAP delivery in
neonates. Endotracheal CPAP is not recommended because it has been found
to increase the work of breathing (infant has to breathe ‘through a straw’).

17. CPAP delivery systems
1
2
3
4
Fig:
1.Nasal mask
2.Nasal prong
3.Long
nasopharyngeal
prong
4.ET tube

18. Advantages disadvantages of CPAP delivery
devices

19. Delivery systems Advantages Disadvantages
Nasal prongs Simple
Lowerresistance leads to
greater transmission of pressure
Difficult to fix
Riskof trauma of nasal septum
Nasopharyngeal prongs Easy availability
Economical
More secure fixation
More easily block by secretions
Likely to get kinked.
Nasal cannulae Ease of application Unreliable pressure delivery
Needhigh flow to generate
pressure
Large leaks around cannula.
Nasal mask Minimal nasal trauma Difficultyin obtaining an
adequate seal

20. Parts of CPAP:

21. CPAP machines in our NICU
Fig: oxygen concentrator CPAP Fig: BUBBLE CPAP

22. How CPAP works?

24. Indications for CPAP

25. When to initiate CPAP?
EarlyCPAP:
Allpreterminfants(<35weeks’gestation)withanysign
ofrespiratorydistress(tachypnea/chest
in-drawing/grunting)shouldbestartedimmediatelyon
CPAP.
Onceatelectasisandcollapsehaveoccurred,CPAPmightnothelp
much.

26. Any signs of significant respiratory distress
Tachypnoea
flaring
grunting
retractions
cyanosis
O
2requirement
Diseases with low functional residual capacity (FRC)
RDS
TTN
Pulmonary oedema
Meconium Aspiration Syndrome
Airway closure disease
BPD
Bronchiolitis
Apnoeaand bradycardia of prematurity
Weaning from mechanical ventilation
Tracheomalacia
Diaphragmatic paralysis
Source: Newborn Services Clinical Guideline(US)

27. ProphylacticCPAP:
SomehaveadvocatedtheuseofprophylacticCPAP(beforetheonsetof
respiratorydistress)inpretermVLBWinfantsasmajorityofthemwould
eventuallydeveloprespiratorydistress.

28. Prophylactic nasal continuous positive airway pressure for
preventing morbidity and mortality in very preterm infants
Cochrane Systematic Review -Intervention Version published: 14
June 2016
Sevenstudiesinvolving3123infants.
Inthefourstudies(765babies)comparingCPAPwithsupportivecare,
CPAPresultedinfewerinfantsrequiringfurtherbreathingassistance.
Inthethreestudies(2354babies)thatcomparedCPAPwithassisted
ventilationwithorwithoutsurfactant,CPAPresultedinasmallbutclinically
importantreductioninBPDandthecombinedoutcomeofBPDandmortality.
Therewasareductionintheneedformechanicalventilationandtheuseof
surfactantintheCPAPgroup.

30. A U T H O R ʼS C O N C L U S I O N S
Use of nasal intermittent positive pressure ventilation (NIPPV) and
nasal continuous positive airway pressure (NCPAP) after extubation
reduces the incidence of extubationfailure within 48 hours to seven
days. Studies using synchronized NIPPV and delivering NIPPV to
infants by a ventilator observed benefits more consistently.
Investigators noted no overall reduction in chronic lung disease
among infants randomized to NIPPV and reported a reassuring
absence of the gastrointestinal side effects that had been reported in
previous case series

31. CPAP is considered to be adequate if a baby on
CPAP is
Comfortable
Has minimal or no chest retractions
Has normal CFT, blood pressure
SpO2 is between 90-95%
Blood gas:
PaO2 is 50 to 80 mmHg
PCO2 is 40 to 60 mmHg
pH is 7.35 to 7.45

32. Study of CPAP in Bangladesh

34. Contraindications to CPAP
1. Progressive respiratory failure with PCO2>60 mmHg and/or inabitity
to maintain oxygenation (PO2<50 mmHg)
2. Certain congenital malformations of the airway
-Choanal atresia
-Cleft palate
-Tracheo-esophageal fistula
-Congenital diaphragmatic hernia
3. Conditions with imminant ventilatory support
-Severe cardio-respiratory compromise
-Poor respiratory drive

35. Essentials of CPAP
Preparing the circuit, the bubble chamber and the machine
Fixing the cap
Securing the nasal prongs or nasal mask
Connecting the circuit
Insertion of orogastrictube
Setting of pressure, FiO2, and flow

37. Setting and Role of Pressure, FiO2 and flow
Pressure:
Ideal range of pressure is from 4 cm to 8 cm of water
Increase or decrease pressure to minimize chest retractions and to
maintain PaO2 > 50mm Hg
FiO2:
Ideal FiO2 is from 21% to 60%
It is adjusted to maintain SPO2 between 90% to 95%
Always increase
pressure before
FiO2 for better
oxygenation
Ref: Work shop on CPAP, AIIMS, New Delhi,
2017

38. Flow:
Range of flow is from 5 to 8 L /min
Flow changes are made only for delivering adequate pressure
To high flow results in wastage of gases, turbulence and inadvertent high pressure

39. Application of CPAP therapy in the three common neonatal conditions
Indications
RDS Apneaof prematurity Post extubation
How to initiate CPAP?
Pressure
Fio2
•6-7cm of H2O
•0.5 (titrate based on
SPO2)
•4-5 cm of H2O
•0.21-0.4
•4-5 cm of H2O
•0.05–0.1above the
pre-extubationFiO2
What to do if there is
no improvement?
Pressure
FIO2
•Increase in steps of 1-2
cm H2O to reach a
maximumof 7-8 cm
H2O
•Increase in steps of
0.05 up to a maximum
of 0.8
•Increase up to 5 cm H2O.
•FiO2increase does not
help much
•Increase in steps of 1-2
cm H2O to reach a
maximumof 7-8 cm
H2O
•Increase in steps of
0.05 up to a maximum
of 0.8
References : Management Protocol of newborn doctor’s Handbook BSMMU
AIIMS Protocols in neonatology

40. Weaning from CPAP
Whentowean?
Whenbabyfulfillsthecriteriaofhaving“OptimumCPAP”
attemptsshouldbetakentoweanfromCPAP
Howtowean?
ReduceFiO2instepsof0.05to0.3,thendecreasepressure
instepsof1-2cmH2Ountil3-4cmH2O
Infant’sclinicalconditionwillguidethespeedofweaning

41. J Perinatol.2017 Jun;37(6):662-667
SuddenversusgradualpressureweanfromNasalCPAPinpreterminfants:a
randomizedcontrolledtrial.
AmatyaS,MacomberM,BhutadaA,RastogiD,RastogiS
OBJECTIVE:Inpreterminfants,nasalcontinuouspositiveairwaypressure(NCPAP)iswidelyusedfortreatmentof
respiratorydistresssyndrome.However,thestrategiesforsuccessfullyweaninginfantsoffNCPAParestillnotwelldefined
andthereremainsconsiderablevariationbetweenthemethods.Theobjectiveofthisstudyistodeterminewhethergradual
weaningofNCPAPpressureismoresuccessfulthansuddenweaningoffNCPAPtoroomair.
Conclusions:
Gradual weaning method was more successful as compared to sudden
weaning method in the initial trial off NCPAP. There was no difference in the
PMA, weight at the time of successful wean.

42. World J Pediatr.2015 Feb;11(1):7-13.
Weaning of nasal CPAP in preterm infants: who, when and how? a systematic review of
the literature.
AmatyaS,RastogiD,BhutadaA,RastogiS.
BACKGROUND: There is increased use of early nasal continuous positive airway pressure (NCPAP) to manage respiratory distress in
preterm infants but optimal methods and factors associated with successful wean are not well defined. A systematic review was
performed to define the corrected gestational age (CGA), weight to wean NCPAP and the methods associated with successful weaning
of the NCPAP among preterm infants, along with factors affecting it.
RESULTS :Seven studies met the search criteria. The successful wean was at 32 to 33 weeks CGA
and at 1600 g. Three different methods were used for weaning were sudden, gradual pressure wean and
gradual graded time off wean. Criteria for readiness, success and failure to wean were defined. Factors
affecting successful weaning were intubation, anemia, infection and gastro-esophageal reflux.
CONCLUSIONS :The successful wean was at 32 to 33 weeks CGA and 1600 g. Criteria for
readiness, success and failure to wean are well defined. Sudden weaning may be associated with a
shorter weaning time. Future trials are needed comparing weaning methods using defined criteria for
readiness and success of NCPAP wean and stratify the results by gestational age and birth weight.

43. Thenasalprongs/nasalmaskcanbesecuredbyputtingonanappropriate
sizedhat
Nasalprongs/nasalmaskmustbeproperlyplacedtopreventairleak
Gentlenasalsuctioningisimportanttomaintainclearairways
Frequentdecompressionoftheinfant’sstomachwithanoro-gastrictubeis
necessary
CareofInfantonCPAP

44. Regularbutgentlenasalsuctiontoclearthemucus4hourlyorasandwhen
required
Cleanthenasalcannulaandcheckitspatencyoncepershift
Changetheinfant’spositionregularlyevery2-4hoursandchecktheskin
conditionfrequentlyforrednessandsores.
Care of Infant on CPAP

45. 1.Vitals:Temperature,respiratoryrate,heartrate,SpO2
2.Assessmentofcirculation:CRT,BP,urineoutput
3.Scoringofrespiratorydistress:SilvermanscoreorwithDowne’sscore
4.Abdominaldistensionmonitoring:bowelsoundsandgastricaspiratestoprevent
CPAPbellysyndrome
5.Neurologicalassessment:Tone,activity,andresponsiveness
6.ChestX-raytochecklungexpansion
7.Bloodgas:Itisdoneonceortwiceadayduringtheacutestageandlaterwhen
clinicallywarranted.
MONITORING WHILE ON CPAP

46. •Suctionthemouth,noseand
pharynx3–4hrly
•Forsymptomaticinfantsmore
frequentsuctioningmaybeneeded
Maintaining Airway While on CPAP

47. •Moistenthenareswithnormal
salineorsterilewatertolubricate
thecatheterandloosendry
secretions
MaintainingAirway While on CPAP

48. •Maintainadequatehumidificationofthe
circuittopreventdryingofsecretions
•Adjustsettingstomaintaingas
humidificationatorcloseto100%
•Setthehumidifiertempto36.5-37.5
o
C
MaintainingAirway : Humidification

49. Complications associated with CPAP
Nasalirritation,damagetotheseptalmucosa,orskindamageandnecrosisfrom
thefixingdevices.
Nasalobstruction
-Removesecretionsandcheckforproperpositioningof
theprongs
Infection
Gastricdistension
CPAPbellysyndrome
IVH
Pneumothorax
Hypoperfusion

50. •Septalinjuryispreventable
•Damagetotheseptumariseswhen
poorlyfittedormobileprongs/nasal
maskcausepressureand/orfriction
Preventing Complications: Nasal SeptalInjury

51. Trauma due to Nasal Mask

52. Indian Pediatr.2010 Mar;47(3):265-7.
Effect of silicon gel sheeting in nasal injury associated with nasal CPAP inpreterm
infants.
GünlemezA,IskenT,GökalpAS,TürkerG,ArisoyEA
Abstract:This study to investigate the efficacy of thesilicongelapplication on the nares in prevention
of nasal injury in preterm infants ventilated withnasalcontinuous positive airway pressure (NCPAP).
Patients (n=179) were randomized into two groups: Group 1 (n=87) had nosilicongelapplied to nares,
and in Group 2 (n=92), thesilicongelsheetingwas used on the surface of nares during ventilation with
NCPAP.Nasalinjurydeveloped in 13 (14.9%) neonates in Group 1 and 4 (4.3%) newborns in Group 2
(OR:3.43; 95% CI: 1.1-10.1; P<0.05). The incidence of columellanecrosis was also significantly higher in
the Group 1 (OR: 6.34; 95% CI: 0.78-51.6; P<0.05).
Conclusion: Thesilicongelapplication may reduce the incidence and the
severity ofnasalinjuryinpreterm infantsonnasalCPAP.

53. Comparison of Nasal Mask Versus Nasal Prongs for Delivering
Nasal Continuous Positive Airway Pressure in Preterm Infants
with Respiratory Distress Syndrome (unpublished)
Thesiswork:DrBipinKarki
Department of Neonatology, BSMMU Shahbagh, Dhaka, Bangladesh
October-2017
Objectiveofthestudy:Tocomparetheefficacyofnasalmaskvsnasal
prongsindeliveringnasalcontinuouspositiveairwaypressureinpreterm
infantswithrespiratorydistresssyndrome.
Conclusion:NCPAPwithmaskinterfaceisequally
effectiveasNCPAPwithprongsinterface.Incidenceof
stageIInasaltraumawassignificantlylowerinmask
groupthanintheprongsgroup.

54. Eur J Pediatr.2017 Mar;176(3):379-386.
Nasalmasksorbinasalprongsfordeliveringcontinuouspositiveairway
pressureinpretermneonates-arandomisedtrial.
ChandrasekaranA,ThukralA,JeevaSankarM,AgarwalR,PaulVK,DeorariAK
Theobjectiveofthisstudywastocomparetheefficacyandsafetyofcontinuouspositiveairwaypressure
(CPAP)deliveredusingnasalmaskswithbinasalprongs.Werandomlyallocated72neonatesbetween
26and32weeksgestationtoreceivebubbleCPAPbyeithernasalmask(n=37)orshortbinasalprongs
(n=35).Incidenceofseverenasaltraumawaslowerwiththeuseofnasalmasks(0vs.31%;p<.001).
CONCLUSIONS:
NasalmasksappeartobeasefficaciousasbinasalprongsinprovidingCPAP.Masks
areassociatedwithlowerriskofseverenasaltrauma.

55. Neonatology 2016;109:258-264
BinasalProng versus Nasal Mask for Applying CPAP to Preterm Infants: A
Randomized Controlled Trial
Say B.KanmazKutmanH.G.OguzS.S.OncelM.YArayiciS.CanpolatF.E.UrasN. KarahanS.
Objective:We aimed to determine whether NCPAP applied with binasalprongs compared to
that with a nasal mask (NM) reduces the rate of moderate/severe bronchopulmonarydysplasia
(BPD) in preterm infants.
Conclusions:
The NM was successfully used for delivering NCPAP in preterm infants, and no
NCPAP failure was observed within the first 24 h. These data show that applying
NCPAP by NM yielded a shorter duration of NCPAP and statistically reduced the rates
of moderate and severe BPD.

56. Topreventgastricdistention:
•Assesstheinfant’sabdomen
regularly
•Passanoro-gastrictubetoaspirate
excessairbeforefeeds
•An5Froro-gastrictubeshouldbe
leftindwellingtoallowforcontinuous
airremoval
CPAP belly
Gaseous distension

57. AJR Am J Roentgenol.1992 Jan;158(1):125-7.
Benigngaseousdistensionof thebowelinpremature
infantstreatedwithnasalcontinuous airway pressure: a study of contributing
factors.
JaileJC,Levin T,WungJT,Abramson SJ,Ruzal-ShapirC,BerdonWE.
AssociatedwiththeincreaseduseofnasalCPAPhasbeenthedevelopmentofmarkedboweldistension(CPAPbelly
syndrome),whichoccursastheinfant'srespiratorystatusimprovesandthebabybecomesmorevigorous.Toidentify
contributingfactors,compared5prematureinfantstreatedwithnasalCPAPwith29premature
infantsnottreatedwithnasalCPAP.Infantswerefollowedupfordevelopmentofdistension,definedclinicallyas
bulgingflanks,increasedabdominalgirth,andvisiblydilatedintestinalloops.Weevaluatedbirthweight,weightattime
ofdistension,methodoffeeding(oral,orogastrictube),andtreatmentwithnasalCPAPandcorrelatedthesefactors
withradiologicfindings.
OftheinfantswhoreceivednasalCPAPtherapy,gaseousboweldistensiondevelopedin83%(10/12)
ofinfantsweighinglessthan1000g,butinonly14%(2/14)ofthoseweighingatleast1000g.Only10%(3/29)
ofinfantsnottreatedwithnasalCPAPhaddistension,andallthreeweighedlessthan1000g.Presenceofsepsisand
methodoffeedingdidnotcorrelatewithoccurrenceofdistension.Neithernecrotizingenterocolitis
norbowelobstructiondevelopedinanyofthepatientswithadiagnosisofCPAPbellysyndrome.
The study shows thatnasalCPAP, aerophagia, and immaturity ofbowelmotility
in very smallinfantswere the major contributors to the development
ofbenigngaseousboweldistension.

58. Am J Perinatol.2011 Apr;28(4):315-20.
Nasalcolonizationamongprematureinfantstreatedwithnasalcontinuous
positiveairwaypressure.
AlyH,HammadTA,OzenM,SandhuI,TaylorC,OlaodeA,MohamedM,KeiserJ.
oNasalcolonizationwithgram-negativebacilliwasincreasedwiththeuseofCPAPinallbirth-
weightcategories(P<0.05)andwithvaginaldeliveryininfantsweighing<1000gand1500to
2499g(P=0.04andP=0.02,respectively).Nasalcolonizationwithanypotentialpathogen
increasedwiththeuseofCPAPinallbirth-weightcategories(P<0.001),withthepresenceof
chorioamnionitisininfants<1000g(P=0.055)andatyoungergestationalageininfants1000
to1499g(P=0.0026).Caucasianinfants1500to2499ghadlesscolonizationthaninfantsof
otherraces(P=0.01).
oNasalCPAPisassociatedwithincreasedcolonizationwithgram-negativebacilli.

59. Indian J Pediatr.2012 Feb;79(2):218-23.
Neurodevelopmental outcomes of extremely low birth weight infants ventilated
with continuous positive airway pressure vs. mechanical ventilation.
Thomas CW,Meinzen-DerrJ,HoathSB,NarendranV.
OBJECTIVE:
To compare continuous positive airway pressure (CPAP) vs. traditional mechanical ventilation (MV) at
24 h of age as predictors of neurodevelopmental (ND) outcomes in extremely low birth weight (ELBW)
infants at 18-22 months corrected gestational age (CGA).
RESULTS:
Ventilatorygroups were similar in gender, rates of preterm prolonged rupture of membranes, antepartum
hemorrhage, use of antenatal antibiotics, steroids, and tocolytics. Infants receiving CPAP weighed more,
were older, were more likely to be non-Caucasian and from a singleton pregnancy. Infants receiving
CPAP had better BSID-II scores (18-22 months of corrected age), and lower rates of BPD and death.
CONCLUSIONS:
After adjusting for acuity differences, ventilatorystrategy at 24 h of age independently predicts long-term
neurodevelopmental outcome in ELBW infants.

60. •TheinfantonCPAPmaybe
positionedsupine,prone,orside
lying(repositioningforatleastevery
3to6hours).
•Whenpositioningsupineorsidelying
supportairwayalignmentwithaneck
roll
Positioning While on CPAP

61. Passanorogastrictube
Keeptheproximalendoftubeopen
IftheinfantisbeingfedwhileonCPAP,closethetubeforhalfan
houraftergivingfeeds
Keepitopenforthenext90minutes(iffed2hourly)
FeedingWhile on CPAP

62. Thebabyrequiresfrequentchangeinposture,oralandnasalsuction
andoccasionallysalinenebulizationforeffectiveremovalofsecretion
shouldbedonepriorto,andafterremovalofCPAP.
Forthe12to24hoursafterremovalofCPAP,carefulmonitoringis
requiredforevidenceoftachypnea,worseningretractions,apneasand
bradycardia.
After removal from CPAP..

63. WorseningrespiratorydistressasindicatedbySilvermanorDowne’sscoring
Apnea>3episodes/hror1episodeneedingbagmaskventilation
ABG:
PCO2>60mmHg)
PO2<50mmHg)
FiO2≥0.6
Ph<7.25
Failure of CPAP

64. Causes of CPAP failure
Delay in initiating CPAP
Intracranial hemorrhage
Progressive metabolic acidosis
Pulmonary edema
Improper fixation of CPAP device and frequent dislodgement
Excessive secretions obstructing the airways or nasal prongs

65. Journal of Tropical Pediatrics, Volume 57, Issue 4, 1 August 2011, Pages
274–279,
Clinical Prediction Score for Nasal CPAP Failure in Pre-term VLBW Neonates with Early Onset
Respiratory Distress
MrinalS. PillaiMari J. SankarKalaivaniManiRamesh AgarwalVinodK. PaulAshokK. Deorari
Abstract:62 pre-term very low birth weight neonates initiated on nasal continuous positive airway
pressure (CPAP) for respiratory distress in the first 24 h of life to devise a clinical score for predicting its
failure. CPAP was administered using short binasalprongs with conventional ventilators. On multivariate
analysis, we found three variables—gestation <28 weeks [adjusted odds ratio (OR) 6.5; 95% confidence
interval (CI) 1.5–28.3], pre-term premature rupture of membranes [adjusted OR 5.3; CI 1.2–24.5], and
product of CPAP pressure and fraction of inspired oxygen ≥1.28 at initiation to maintain saturation
between 88% and 93% [adjusted OR 3.9; CI 1.0–15.5] to be independently predictive of failure. A
prediction model was devised using weighted scores of these three variables and lack of exposure to
antenatal steroids. The clinical scoring system thus developed had 75% sensitivity and 70% specificity
for prediction of CPAP failure (area under curve: 0.83; 95% CI 0.71–0.94).
Conclusion:
A simple clinical score comprising four variables namely, gestational age <28 weeks, PPROM,
lack of exposure to ANS, and product of CPAP pressure and FiO
2≥1.28 would predict failure of
nasal CPAP in pre-term VLBW infants with reasonable accuracy.

66. Pediatrics July 2016, VOLUME 138 / ISSUE 1
Incidence and Outcome of CPAP Failure in Preterm Infants
Peter A. Dargaville,Angela Gerber,Stefan Johansson,Antonio G. De Paoli,C. Omar F. Kamlin,Francesca
Orsini,Peter G. Davis,for the Australian and New Zealand Neonatal Network
RESULTS:Withinthecohortof19103infants,11684wereinitiallymanagedonCPAP.FailureofCPAP
occurredin863(43%)of1989infantscommencingonCPAPat25–28weeks’gestationand2061
(21%)of9695at29–32weeks.CPAPfailurewasassociatedwithasubstantiallyhigherrateof
pneumothorax,andaheightenedriskofdeath,bronchopulmonarydysplasia(BPD)andother
morbiditiescomparedwiththosemanagedsuccessfullyonCPAP.TheincidenceofdeathorBPDwas
alsoincreased:(25–28weeks:39%vs20%,AOR2.30,99%confidenceinterval1.71–3.10;29–32
weeks:12%vs3.1%,AOR3.62[2.76–4.74]).TheCPAPfailuregrouphadlongerdurationsof
respiratorysupportandhospitalization.
CONCLUSIONS:
CPAP failure in preterm infants is associated with increased risk of mortality and major
morbidities, including BPD. Strategies to promote successful CPAP application should be
pursued vigorously.

67. Iftheinfantdevelopsfrequentapneaandbradycardiaepisodes,tachypnea
orretractions,thenCPAPisreintroduced
Indications for reintroducing CPAP

68. J Perinatol.2016 May;36 Suppl1:S21-8.
Efficacy and safety of CPAP in low-and middle-income countries.
ThukralA,SankarMJ,ChandrasekaranA,AgarwalR,Paul VK.
oPooledanalysisoffourobservationalstudiesshowed66%reductioninin-hospitalmortality
followingCPAPinpretermneonates(oddsratio0.34,95%confidenceinterval(CI)0.14to0.82).
Onestudyreported50%reductionintheneedformechanicalventilationfollowingtheintroduction
ofbubbleCPAP(relativerisk0.5,95%CI0.37to0.66).
oTheproportionofneonateswhofailedCPAPandrequiredmechanicalventilationvariedfrom20to
40%(eightstudies).
oAvailableevidencesuggeststhatCPAPisasafeandeffectivemodeoftherapyinpretermneonates
withrespiratorydistressinLMICs.Itreducesthein-hospitalmortalityandtheneedforventilation
therebyminimizingtheneedforup-transfertoareferralhospital.

69. NasalCPAPisaneffective,saferandpreferredmodeoffirstline
therapyinthemanagementofrespiratorydistressinpretermneonates.
EarlyCPAPinpreterminfantswithrespiratorydistressalsoreduces
theneedforsurfactanttherapy.
Take Home message

71. WELCOME TO THE SEMINAR
Dr. PoonamBodh
Dr. TareqRahman
Resident, year-4
Department of Neonatology
BSMMU

72. Headlines
Criteria of CPAP failure with failure rates
Clinical
ABG
Causes of CPAP failure
Infant Characteristics
Predictors of CPAP failure
Diligent nursing care and experience of Using CPAP
Outcome of CPAP Failure

73. Failure of CPAP
CPAP failure is considered;
-FiO2 > 60%
-Pressure > 7 cm of water
-A baby continuing to have retractions, grunting and
recurrent apnea on CPAP
-Inability to maintain SpO2 > 90% or PaO2 < 50 mm of Hg
with FiO2 ≥ 60% and pressure > 7cm of water and
PaCO2 > 60 mm of Hg, PH < 7.25

74. Causes of CPAP failure
Delay in initiating CPAP
Intracranial hemorrhage
Progressive metabolic acidosis
Pulmonary edema
Improper fixation of CPAP device and frequent
dislodgement
Excessive secretions obstructing the airways or
nasal prongs

75. Table 1: Criteria for CPAP failure with failure rates in preterm infants
Failure
Rate
(25-26
wks)
55%
(27-28
wks)
40%
Early
CPAP –
39%
Insure –
26%
67.1%

76. CPAP
Group –
33%
Insure
group–
33.4%
17.9 % in
CPAP
group

77. The factors determining the success of CPAP
choosingtherightinfant(weightandunderlyingdisease
process),applyingitearlyratherthanlate.
knowingthemachinewell,diligentnursingcareandthe
convictionoftheteam.
Thethresholdcriteriausedtodefinefailure,willdetermine
theCPAPfailurerates.Withincreasingexperiencethe
successratesarelikelytoimprove.

78. Infant characteristics
Verysmallbabies(<750grams)maynothavegood
respiratoryeffortswhiletermbabiesmaynottoleratethe
nasalprongs.CPAPislikelytohaveleastfailuresinbabies
between750-1750grams,butitcanbesuccessfulinsmallest
andbiggerbabies.
CPAPismostsuccessfulinbabieswithmildtomoderate
respiratorydiseaseespeciallyhyalinemembranediseaseand
apneaofprematurity.
ItislesslikelytobesuccessfulinbabieswithCNSpathology
e.g.severeasphyxiaorsystemicsepsis.
Babiesexposedtoantenatalsteroidsarelikelytohavemilder
diseaseandmorelikelytosucceedwithCPAP.

79. J Pediatr2005;147:341-7
VARIABLES ASSOCIATED WITH THE EARLY FAILURE OF NASAL CPAP IN VERY
LOW BIRTH WEIGHT INFANTS
AMERAMMARI,MB,BS,MANDHIRSURI,MD,VLADANAMILISAVLJEVIC,MD,RAKESHSAHNI,MD,
DAVIDBATEMAN,MD,ULANASANOCKA,MD,CARRIERUZAL-SHAPIRO,MD,JEN-TIENWUNG,MD,
ANDRICHARDA.POLIN,MD
Results:
CPAPwassuccessfulin76%ofinfants#1250gbirthweightand50%ofinfants#750
gbirthweight.Inanalysesadjustedforpostmenstrualage(PMA)andsmallfor
gestationalage(SGA),CPAPfailurewasassociatedwithneedforpositivepressure
ventilation(PPV)atdelivery,alveolar-arterialoxygentensiongradient(A-aDO2)
>180mmHgonthefirstarterialbloodgas(ABG),andsevereRDSontheinitialchest
x-ray(adjustedoddsratio[95%CI]=2.37[1.02,5.52],2.91[1.30,6.55]and6.42
[2.75,15.0],respectively).Thepositivepredictivevalueofthesevariablesranged
from43%to55%.InanalysesadjustedforPMAandsevereRDS,ratesofmortality
andcommonprematuremorbiditieswerehigherintheCPAP-failuregroupthaninthe
CPAP-successgroup.
Conclusion:
Althoughseveralvariablesavailablenearbirthwerestronglyassociatedwithearly
CPAPfailure,theyprovedweakpredictorsoffailure.Aprospectivecontrolledtrialis
neededtodetermineifextremelyprematurespontaneouslybreathinginfantsare
betterservedbyinitialmanagementwithCPAPormechanicalventilation.

80. Neonatology.2013;104(1):8-14.
Continuous positive airway pressure failure in preterm infants: incidence,
predictors and consequences.
DargavillePA,AiyappanA,De Paoli AG,Dalton RG,KuschelCA,KamlinCO,OrsiniF,Carlin JB,Davis PG
METHODS:
Preterminfants25-32weeks'gestationwereincludedinthestudyifinbornandmanagedwithCPAP
astheinitialrespiratorysupport,withdivisionintotwogestationrangesandgroupingaccordingto
whethertheyweresuccessfullymanagedonCPAP(CPAP-S)orfailedonCPAPandrequired
intubation<72h(CPAP-F).PredictorsofCPAPfailureweresought,andoutcomescompared
betweenthegroups.
RESULTS:
297infantsreceivedCPAP,ofwhich65(22%)failed,withCPAPfailurebeingmore
likelyatlowergestationalage.MostinfantsfailingCPAPhadmoderateorsevere
respiratorydistresssyndromeradiologically.Inmultivariateanalysis,CPAPfailure
wasfoundtobepredictedbythehighestFiO₂inthefirsthoursoflife.CPAP-F
infantshadaprolongedneedforrespiratorysupportandoxygentherapy,anda
higherriskofdeathorbronchopulmonarydysplasiaat25-28weeks'gestation
(CPAP-F53%vs.CPAP-S14%,relativerisk3.8,95%CI1.6,9.3)anda
substantiallyhigherriskofpneumothoraxat29-32weeks.
CONCLUSION:
CPAPfailureinpreterminfantsusuallyoccursbecauseofunremittingrespiratory
distresssyndrome,ispredictedbyanFiO₂≥0.3inthefirsthoursoflife,andis
associatedwithadverseoutcomes.

81. J Perinatol.2016 May;36 Suppl1:S21-8.
Efficacy and safety of CPAP in low-and middle-income countries.
ThukralA,SankarMJ,ChandrasekaranA,AgarwalR,Paul VK.
oPooledanalysisoffourobservationalstudiesshowed66%reductioninin-
hospitalmortalityfollowingCPAPinpretermneonates(oddsratio0.34,95%
confidenceinterval(CI)0.14to0.82).Onestudyreported50%reductioninthe
needformechanicalventilationfollowingtheintroductionofbubbleCPAP
(relativerisk0.5,95%CI0.37to0.66).
oTheproportionofneonateswhofailedCPAPandrequiredmechanicalventilation
variedfrom20to40%(eightstudies).
oAvailableevidencesuggeststhatCPAPisasafeandeffectivemodeoftherapyin
pretermneonateswithrespiratorydistressinLMICs.Itreducesthein-hospital
mortalityandtheneedforventilationtherebyminimizingtheneedforup-transfer
toareferralhospital.

85. Diligent Nursing Care and Experience of Using CPAP
Thequalityofnursingcareisequallyimportantindecidingoverall
successrate.Theattentionshouldbegiventoallthedetailsincluding
clinicalfrequentexaminationofInfants;
BabyisnotfightingtheCPAPinterface
•Nasalprongsornasalmasksareofcorrectsizeandareinposition
•Humidificationisadequateandthereisnocondensationinthe
circuit
•AdequatepressureandFiO2,aredelivered(neckposition,clear
nostrilsandairway)

86. Pediatrics,2004 Sep;114(3):697-702.
Does the experience with the use of nasal continuous positive airway
pressure improve over time in extremely low birth weight infants?
AlyH,Milner JD,Patel K,El-MohandesAA.
RESULTS:
Therewerenosignificanttrendsinmortalityrateamongthebaselinegroupandthe3tercilessince
theinstitutionoftheENCPAPpractice(26.7%vs26.5%vs11.8%vs18.2%).ENCPAP
managementincreasedinthesurvivinginfantsovertime(14%vs19.2%vs65.52%vs70.4%),
whereastheuseofsurfactantdecreased(51.5%vs48%vs13.3%vs33.3%)andtheincidenceof
bronchopulmonarydysplasia(BPD)decreased(33.3%vs46.2%vs25.9%vs11.1%).Theaverage
ventilatordaysperinfantdecreased,therateofsepsisdecreased,andtheaveragedailyweight
gainincreased.Therewerenosignificanttrendsintheincidenceofintraventricularhemorrhageor
necrotizingenterocolitis(NEC).Whencomparingthecohortsofsurvivorsinthe3tercilessincethe
institutionofENCPAPsystem,ELBWinfantswhowerestartedonENCPAPbutintubatedwithin1
week(CPAPfailure)decreasedovertime(38.5%vs13.8%vs7.4%).Therewereothertrendsthat
didnotreachsignificance,suchasincreasedincidenceofnecrotizingenterocolitis(NEC).Ina
multivariateanalysiscontrollingforgestationalage,birthweight,andsepsis,theincidenceofBPD
wassignificantlylowerovertime(regressioncoefficient=-1.002+/-0.375).
CONCLUSIONS:
ThefrequencyofuseofENCPAPinELBWinfantsanditssuccessimprovedinourunitovertime.
ThemajorpositiveassociationinthispopulationwasareductioninBPDratesandanincreasein
averageweightgain.RelationofENCPAPandNECshouldbeevaluatedfurther.

87. Pediatrics. 2016;138(1)
Incidence and Outcome of CPAP Failure in Preterm Infants
Peter A. Dargaville, FRACP, MD, Angela Gerber, MD, Stefan Johansson, MD, Antonio G. De Paoli, FRACP, MD,
Omar F. Kamlin, FRACP, DMedSci, Francesca Orsini, BSc, MSc, Peter G. Davis, FRACP, MD.
METHODS:
DatafrominbornpreterminfantsmanagedonCPAPfromtheoutsetwereanalyzedin2
gestationalageranges(25–28and29–32completedweeks).OutcomesafterCPAPfailure
(needforintubation<72hours)werecomparedwiththosesucceedingonCPAPusingadjusted
oddsratios(AORs).
RESULTS:
Withinthecohortof19103infants,11684wereinitiallymanagedonCPAP.FailureofCPAP
occurredin863(43%)of1989infantscommencingonCPAPat25–28weeks’gestationand
2061(21%)of9695at29–32weeks.CPAPfailurewasassociatedwithasubstantiallyhigher
rateofpneumothorax,andaheightenedriskofdeath,bronchopulmonarydysplasia(BPD)and
othermorbiditiescomparedwiththosemanagedsuccessfullyonCPAP.Theincidenceofdeath
orBPDwasalsoincreased:(25–28weeks:39%vs20%,AOR2.30,99%confidenceinterval
1.71–3.10;29–32weeks:12%vs3.1%,AOR3.62[2.76–4.74]).TheCPAPfailuregrouphad
longerdurationsofrespiratorysupportandhospitalization.
CONCLUSIONS:
CPAPfailureinpreterminfantsisassociatedwithincreasedriskofmortalityandmajor
morbidities,includingBPD.StrategiestopromotesuccessfulCPAPapplicationshouldbe
pursuedvigorously.