CPAP IN NEONATE

n.shruthi

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 Definition of Common Terms

1. Tidal Volume: This is the volume of air inspired or expired in each breath.
2. Functional residual capacity FRC: It is a measure of the volume of the lungs at end
expiration. It is critical that the infant has an adequate volume of gas in the lungs at the
end of expiration, i.e. an FRC. It is critical for effective gas exchange that newborns
quickly achieve and maintain an FRC. The key determinant of FRC in ventilated infants is
the mean airway pressure (MAP).
3. Mean airway pressure (MAP): It is the average pressure in the respiratory passage during
ventilation. It is determined by the inspiratory flow rate, PIP, Ti, PEEP and ventilator rate.
4. Inspiratory time (Ti) and Expiratory time (Te): Time allowed for inflow and outflow of the
air-gas mixture. I:E ratio: Ratio between inspiratory time and expiratory time.
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5. Peak inspiratory pressure (PIP): Highest pressure reached during the inspiratory phase. It
is guided by good chest excursions and air entry.
6. Positive end expiratory pressure (PEEP), is a pressure applied by the ventilator at the end
of each breath to ensure that the alveoli are not so prone to collapse. This ‘recruits’ the
closed alveoli in the sick lung and improves oxygenation.
7. FiO2 : Fraction of oxygen in the inspired air gas mixture.
8. PaO2 : This denotes the partial pressure of O2 in arterial blood.
9. PaCO2 : This denotes the partial pressure of CO2 in arterial blood.
10. SpO2 : This denotes the oxygen saturation of hemoglobin in arterial blood.
11. Compliance. It is the stiffness or distensibility of the lung and chest wall, i.e., the change
in volume produced by a change in pressure.
12. Resistance: It is the sum of the impediment to airflow due to friction between gas and
airway (airway resistance) and between tissues of the lung and chest wall (viscous
resistance). 3
 CPAP - Introduction
1. CPAP, also called continuous distending pressure (CDP), refers to the application of
continuous pressure during both inspiration and expiration in a spontaneously breathing
baby.
2. By providing constant airway pressure, the alveoli are kept open which increases the
functional residual capacity (FRC) of the lungs resulting in better gas exchange.
3. CPAP increases the FRC to a level above the closing volume so that the terminal airways
remain open throughout the respiratory cycle.
4. Thus smaller (diameter) alveoli will have a tendency to empty into larger (diameter)
alveoli connected to each other. By giving CPAP, one neutralizes the inward collapsing
pressure. 4
 Physiological benefits of CPAP

1. results in improved oxygenation, wash out of CO2, and better blood pH.

2. splints the upper airways thus preventing obstructive apnea.

3. stimulates ‘J’ receptors by stretching the lung/pleura and providing positive

feedback to respiratory centre by Hering Bruer reflex.

4. results in better Type II-pneumocyte function and even recycling of

surfactant thus contributing to early recovery from HMD.

5. results in better ventilation-perfusion match, improved minute ventilation

and decreased work of breathing. 5
 Disadvantages of conventional
ventilation (CV)
1. CV of premature lung results in inflation and deflation of alveoli at high pressure (Barotrauma);
tidal volumes (volutrauma); few alveoli collapse & reopen from collapsed stage resulting in
atelecto-trauma.

2. In addition, endotracheal tube is a foreign material resulting in inflammation & infection

(Biotrauma).

3. Using nasal CPAP would avoid most of the ill effects of mechanical ventilation.

4. Use of CV results in rupture of interalveolar septa thus decreasing the surface area for gas
exchange despite increasing lung volume.

5. In animal models, as little as 72 hours of CV has been shown to result in thickened alveolar
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septa.
 CPAP
1. Effect on lung growth:
CPAP promotes growth in premature lung, as evidenced by increased DNA
and protein per gm of lung tissue following CPAP application, while
conventional ventilation initiates inflammatory response in the lung as
evidenced by increased polymorphs and free oxygen radicals in the lung
lavage.
2. Effect on compliance:
Animal experiments have demonstrated that lung compliance of premature
lung following 28 days of CPAP application either matches that of a term lung
or is better. In contrast lung compliance is reduced following conventional
ventilation.
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3. Effect on pulmonary vasccular resistance:
By providing optimal CPAP , the lung is kept open at the FRC. The architect
of blood vessels in the lung is such that, PVR is least at FRC and increases
when the lung volume is reduced below FRC (HMD) or increased above FRC
(Meconium Aspiration Syndrome).

4. Work of breathing:
CPAP dilates terminal airways thus decreasing resistance to air flow,
improving tidal volume for spontaneous breaths. Overall minute ventilation
improves, resulting in washing down the CO2.
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 Indications & Contraindications
1. Neonate should have good respiratory effort. CPAP is indicated in spontaneously
breathing premature infant with respiratory distress (tachypnea, retractions or grunt),
recurrent apneas not responding to medical management and post extubation from
mechanical ventilation.
2. In at-risk neonates for respiratory distress syndrome, CPAP should be started at the
earliest sign of respiratory distress.
3. CPAP is also indicated in term neonates with respiratory distress and saturations less
than 90% on hood oxygen.
Contraindications:
4. In neonates with poor respiratory efforts, congenital diaphragmatic hernia, tracheo-
esophagial fistula, choanal atresia, cleft palate and in those with severe cardio-vascular
instability, CPAP is contraindicated.
5. CPAP is also contraindicated when the pH is less than 7.25 and PaCO2 >60 mm of Hg.
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 The steps of initiation of CPAP
1. Preparing the circuit, the bubble chamber and the machine

2. Fixing the cap

3. Securing the nasal prongs or nasal mask

4. Connecting the circuit

5. Insertion of orogastric tube

6. Setting of pressure, FiO , and Flow

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 Setting of pressure, FiO2 and Flow

Pressure
1. This is increased or decreased by increasing or decreasing the depth of immersion of
expiratory limb into the bubble chamber (water level being constant) or directly by
dialing the knob on the pane when administering CPAP with a ventilator. Pressure is
adjusted by regulating the flow in a flow driver.

2. Start with a pressure of 5cm H2O in case of RDS or Pneumonia and a pressure of 4cm

H2O for apnea management

3. Pressure is adjusted to minimize chest retractions and to observe 6 to 8 posterior rib

spaces on the Chest x ray.
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Flow
Keep the flow rate at 5 liters/min. Watch for bubbling in the bubble chamber. In case of
poor or no bubbling check for leaks in the circuit or increase flow rate.

FiO2
1. Start with a FiO2 of 50% and after adjusting the pressure, titrate the FiO2 to maintain

SpO2 between 90 to 94%.

2. In the absence of a blender, for adjusting FiO2 mix air and oxygen gas flows to get

the desired FiO2 using a matrix or a chart or the following formula:

FiO2 delivered to the patient = (1 Oxygen flow) + (0.21 air flow)
Total gas flow reaching the patient 13
 Maintenance and monitoring of a neonate on CPAP

Adjustment of pressure, FiO2 and Flow:

1. Ideal range of pressure for a baby on CPAP is from 4cm to 8 cm of water.
2. Increase or decrease pressure to minimize chest retractions, maintain 6 to 8 posterior rib
spaces on the CXR and to maintain PaO2 > 50mm Hg.
3. Silverman scoring is an objective method to assess the efficacy of CPAP.
4. High pressure results in hyper-inflated lungs, decreased venous return, poor capillary
perfusion and metabolic acidosis.
5. Ideal FiO2 for a baby on CPAP is from 21% to 60%. FiO2 is adjusted to maintain SpO2
between 90% to 94%.
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 Nurse On Duty

1. Ensure correct position and fixation of the nasal prongs

2. Clean the nostrils with saline drops, suction the secretions and ensure
patency of prongs
3. Prevent injury to the nasal septum by ensuring a gap between the nasal
prongs and columella
4. Remove condensed water in the inspiratory circuit
5. Fill the humidification chamber and ensure that the gas reaching baby
should be at 37°C and at 100% relative humidity
6. Fill the bubble chamber with clean water 15
 Monitoring vitals
1. Vitals : Heart rate, Temperature, Respiratory rate, Blood pressure and SpO2
2. Assessment of circulation : Capillary refill time, blood pressure and urine output
3. Scoring of respiratory distress: It can be done with Silverman score or with Downe's
score.
4. Abdominal distension monitoring: bowel sounds and gastric aspirates to prevent CPAP
belly
5. Neurological status assessment : Tone, activity and responsiveness
6. CXR : It is done at the starting of CPAP and as and when there is a clinical deterioration
7. Blood gas : It is done once or twice a day during the acute stage and later when clinically
warranted. Capillary blood gases are preferred. 16
 CPAP is considered to be adequate if a baby
on CPAP is
1. Comfortable

2. Has minimal or no chest retractions

3. Has normal CFT, blood pressure

4. SpO2 is between 90 to 94%.

5. Blood gas : PaO2 is 50 to 80 mm Hg, PCO2 is 40 to 60 mm Hg and pH is

7.35 to 7.45.
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 Weaning of CPAP

1. CPAP for apneas may be removed after 24 to 48 hours of apnea free interval.

2. Always wean pressure before weaning of FiO2. For a baby on FiO2 > 50% and
CPAP pressure >5 cm, wean FiO2 till it reaches 50% and then wean the
pressure. Once the FiO2 is at 50% wean it a level <30% before reducing CPAP
pressure from 5 to 4 cm.

3. When a baby is on a pressure of 4cms with a FiO2 < 30% with normal
saturations and minimal retractions, CPAP may be removed.

4. One may use HHHFNC when weaning a baby from CPAP. 18

 Failure of CPAP
1. CPAP failure is considered when the FiO2 required is greater than 60% and pressure required is
greater than 7 cm of water. A baby continuing to have retractions, grunting and recurrent apnea on
CPAP should be considered for mechanical ventilation.

2. 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 on CPAP are also indications for mechanical ventilation.

3. Before considering CPAP failure ensure the following criteria:

1. Baby is not fighting the CPAP interface

2. Nasal prongs are of correct size and are in position

3. Humidification is adequate and there is no condensation in the circuit

4. Adequate pressure and FiO2, are delivered (neck position, clear nostrils and airway) 19
Heated Humidified High Flow
Nasal Cannula

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 Heated Humidified High Flow Nasal Cannula

• The use of heated humidified high-flow nasal cannula (HFNC) has emerged as
an alternative to CPAP in recent years for:
1. Its ease of application and maintenance,

2. Less nasal trauma, better tolerance,

3. Better access for care giving, skin-to-skin care and feeding.

• HFNC therapy refers to the administration of oxygen or blended oxygen and air
to neonates via nasal cannulae at higher flow (greater than 1 L/min.).

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 Mechanism of action of HFNC

1. The heated and humidified gas decreases the metabolic work of breathing and
reverses the dryness and mucosal injury that would otherwise occur at high gas
flow rates

2. Delivery of positive distending pressure to the airway recruits alveoli and stabilizes
the both large and small airways and the alveoli at end-expiration thus maintaining
FRC. This in turn improves oxygenation and decreases the work of breathing.

3. The high gas flow rate washes the nasopharyngeal dead space of carbon-dioxide
and entrains fresh gas mixture.
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 Equipment

1. The Precision Flow (Vapotherm, Exeter, NH, USA) the Optiflow Junior (Fisher & Paykel,
Auckland, New Zealand) are two common devices used for the delivery of HFNC.
2. The essential parts of a Fisher and Paykel HFNC system are described below:
1. Oxygen and air source
2. Blender: FiO2 can be adjusted in increments of 1% from 21- 2 100%
3. Flow meter: Standard (0-15 L/min) flow meter is used. In neonates, flow rates should
not exceed more than 8 L/min.
4. Humidifier: Should be set at 370C. At flow rates of 1-4 L/min, both Optiflow and
Vapotherm devices achieve an oro-pharyngeal temperature of 33-340 C and relative
humidity (RH) of > 96%.
5. Circuit tubing to attach to humidifier
6. Nasal cannula (prongs) to attach to humidifier circuit tubing
7. Water bag for humidifier
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 Indications for use of HFNC in neonates
1. Post extubation support: HFNC is used as alternative to CPAP for post-extubation
support in preterm neonates.
2. To aid in weaning from CPAP in preterm neonates.
3. As an alternative to CPAP in stable preterm neonates who are at risk of or have
established nasal trauma or for better nursing care to promote mother-infant bonding,
kangaroo care and oral feeding.
4. As a primary mode of support in preterm neonates with RDS.
Contra-indications:
Neonates with severe RDS, recurrent apnea, pneumothorax and cranial and airway
anomalies are not suitable candidates for HFNC therapy. 24
 Initiation and escalation and weaning of HFNC therapy

1. Nasal cannula should occupy less than 50% of the area of the aperture of the nostril to allow
ample egress of expired gas.

2. Setting flow rates: for 1000 to 1999 g = 3 L/min, for 2000 to 2999 g = 4 L/min, and for 3000 g =
5 L/min.

3. FiO2 : Begin at 40% or FiO2 similar to ventilatory or CPAP settings. Pulse oximeter should be
used to titrate FiO2 .

4. Conditioning of respiratory gases: The humidifier should be set at 370C.

5. Monitoring during therapy: Monitoring should include respiratory rate, heart rate, chest
retractions and degree of chest-in drawing. Use of an objective scoring system like the
Silverman score is recommended. 25
6. Escalation of therapy: Flow rates can be increased in increments of 1 L/min
up to a maximum of 8 L/min in response to increased chest retractions,
tachypnea and increased oxygen requirement.
7. Failure of HFNC:
a. Increasing FiO2 requirement >40%,
b. Respiratory acidosis (ph £ 7.2 and pco2 > 60 mm hg) or
c. Recurrent episodes of apnea requiring positive pressure ventilation
8. Weaning of HFNC:
a. Once the neonate is stable on HFNC for 12-24 hours, one can consider weaning.
b. FiO2 is weaned first and then the flow rate in decrements of 1 L/min every 12 or 24
hours, guided by work of breathing and oxygen requirement.
c. Once a flow rate of 2 L/min is reached, HFNC can be discontinued.
d. Neonates requiring minimal oxygen prior to discontinuation may need to be placed
on low flow titrated oxygen therapy. 26
Low flow oxygen
therapy

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 Differences between high flow and low flow devices

1. Flow Rate:- Flow rate for low flow devices is lower than the normal inspiratory flow rate of the patient
which is usually from 20 liters/min to 30 liters/min. The patient gets the remaining portion of the air from
the atmosphere. On the other hand, high-flow devices supply more air than the required inspiratory flow
rate of the patient.
2. Fraction of Inspired Oxygen (FiO2):- The value of FiO2 remains constant for the high-flow devices. However,

for the low-flow devices, the value of FiO2 cannot remain fixed.
3. Temperature:- Air is supplied at a normal atmospheric temperature in the case of low flow devices. But, in
the case of high-flow devices, it supplies air that is generally warm and humid. This allows maximizing the
tolerance of the patient.
4. Examples:- Some of the common examples of high flow devices include venturi mask, jet nebulizer, high
flow nasal cannula, etc. On the other hand, low flow devices include nasal cannula, partial rebreathing
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mask, normal (aerosol) mask, etc.
 Oxygen Delivery Devices
Oxygen Delivery

Low Flow Systems High Flow Systems

Reservoir HFNC
Nasal Canula Simple Mask Venturi Mask
Mask Blenders

Partial
Non Rebreather
Rebreather
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 Nasal Prongs
1. Nasal prongs are a device that ends in two short tapered tubes (about 1 cm in length)
designed to lie just within the nostrils. They are also called nasal cannulae.
2. Standard flow rates through nasal prongs are 0.5–1 L/min for neonates, 1–2 L/min for
infants, 1–4 L/min for older children.
3. There is no risk of gastric distension at standard flow rates, as they cannot be inserted too
far into the nasal passage.
4. Humidification is not required with standard oxygen flow rates, as the natural nasal
mechanisms heat and humidify the inspired oxygen.
5. There is a slight risk that the airway will become obstructed by mucus.
6. In infants weighing up to 10 kg, oxygen flows of 0.5 L/min, 1 L/min and 2 L/min result in
FiO2 values of about 35%, 45% and 55%, respectively.
7. PEEP production with nasal prongs is unpredictable. 1 L/min of oxygen may produce a
PEEP of about 5 cm H2O in premature infants, there is no significant PEEP production with
the same flow in infants weighing up to 10 kg 30
Nasal Prongs

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 Nasal Prongs

Advantages Disadvantages

1. Can not provide high flow oxygen

1. Ideal for patients on long-
2. Irritation and cannot be used in nasal
term oxygen therapy obstruction

2. Light weight and comfortable 3. FiO2 varies with respiratory efforts

4. Easily dislodged,
3. The patient is able to speak,
5. Not as effective is a patient is a mouth
eat and drink
breather or has blocked nostrils

4. Low cost 6. High flow rates are uncomfortable

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 Nasal Catheter
1. A nasal catheter is a thin, flexible tube that is passed into the nose and ends with its tip in
the nasal cavity. The tip of the catheter should not be visible below the uvula.
2. The oxygen does not have to be humidified because the tip of the catheter lies in the nasal
cavity.
3. Catheters can become blocked with mucus. There is risk of displacement into the
oesophagus, with a consequent risk of gastric distension.
4. Ideally, a nasogastric tube should be in place to decompress the stomach if distension
occurs.
5. In neonates and infants, 8-French (F) size catheters should be used. A catheter passed for a
distance equal to the distance from the side of the nostril to the inner margin of the
eyebrow. In infants, this is about 2.5 cm.
6. The maximum flow rate should be set at 0.5–1 L/min for neonates and 1–2 L/min for
infants and older children. FiO2 = 35-40%
7. No advantages over nasal cannula 33
Nasal Catheter

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 Nasopharyngeal catheters

1. This type of catheter is passed to the pharynx just below the level of the uvula.
2. Oxygen delivery through a nasopharyngeal catheter is the most economical of all the
methods described here.
3. Better oxygenation is achieved with a lower oxygen flow than with nasal prongs, because of
the relatively high FiO2 in the trachea and significant PEEP production: in infants, 1 L/min of
nasopharyngeal oxygen given through an 8-F catheter produces a PEEP of 2.8 cm H2O.
4. Because of reliable production of moderate PEEP, suitable for patients with severe hypoxia.
5. Nasopharyngeal oxygen delivery may also be used in hospitals with very limited oxygen
supply,
6. Nasopharyngeal catheters are prone to blockage with mucus, and accumulation of mucus
can cause upper airway obstruction.
7. Nasopharyngeal catheters can be displaced downwards into the oesophagus and cause
gagging, vomiting and gastric distension.
8. The maximum flow rate should be set at 0.5 L/min for neonates and 1 L/min for infants.
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 Simple Face Mask

1. It can carry upto 5 – 10Litres of O2 per Minute with FIO2

0.35 – 0.55 (approximate flowrate of 40%).
2. Flowrates should be set at 5 L/min or more to avoid
rebreathing expired CO2 retained in the mask.
3. It slightly increases dead space and there is little
rebreathing[.
4. Transparent mask provided with side holes
5. Different oxygen flow rates result in a highly variable and
unpredictable FiO2
6. Rebreathing of CO2 can occur with oxygen flow rates of
less than 2L oxygen/min or if minute ventilation is very
high
7. Flow rates greater than 8L/min do not increase FiO2 37
 Simple Face Mask
Disadvantages:
Advantages:
1. Uncomfortable
1. Less expensive
2. It is usually uncomfortable for patients, obstruct eating
2. Can be used in mouth
and drinking and also, muffles speech.
breathers
3. Require tight seal
4. Do not deliver highFiO2
5. FiO2 varies with breathing efforts
6. Interfere with eating, drinking, communication
7. Difficult to keep in position for long
8. Chances of rebreathing are high
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 Rebreathing masks

1. A Rebreathing mask is one of the oxygen delivery devices. It is a kind of aerosol mask
that consists of a reservoir bag at the bottom.

2. These reservoir bags have a volume of about 1 liter to store pure oxygen. Thus the bag
should always be at least 1/3 or 1/2 inflated with oxygen.

Drawbacks of Rebreathing Mask

3. Possibility of neither eating nor talking using this mask

4. Chances of skin irritation around the nose and ear

5. Chances of air leakage from the mask

6. Might need to adjust the mask from time to time 39

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Partial Rebreathing Mask Non- Rebreathing Mask

Since there is no valve in the mask, there There may be one, two, or more valves and allow
is a partial chance of exhaled air being the one-way flow of the gas and thus there is no
inspired again. chance of inhaling the exhaled gas.

FiO2 ranges from 60% to 80% for a single valve

The fraction of inspired oxygen (FiO2)
mask. In the case of a double valve mask, it can go
ranges from 40% to 70%. up to 100%.
It is a low-flow device. It may either be a low-flow or high-flow device.
Flow rate ranges from 8 to 15 liters per
minute. Flow rate ranges from 10 to 15 liters per minute.

There is no risk for the suffocation of the If the valve gets damaged then the patient will
patient. experience suffocation.

Generally, used for a longer period of Generally, used for a short period of time only. For
time. example, during transportation of the patient.
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