Beruflich Dokumente
Kultur Dokumente
A i r w a y P re s s u re
To Bubble or Not to Bubble?
Samir Gupta,
a,
*, Steven M. Donn,
MD
KEYWORDS
Continuous positive airway pressure, CPAP Bubble CPAP Ventilation
Respiratory support
KEY POINTS
Bubble continuous positive airway pressure (CPAP) has physiologic properties that could
facilitate gas exchange.
Bubble CPAP (bCPAP) has been successfully used in resource-poor settings.
bCPAP is reported to improve success after extubation in preterm babies ventilated for
less than 2 weeks.
The success on CPAP is dependent on good nursing care and clear management protocols for weaning and escalation of care.
Minimizing nasal injuries and improvising systems for optimizing CPAP delivery should be
the focus of further investigations.
INTRODUCTION
perinatology.theclinics.com
648
support spontaneously breathing infants using bubble CPAP (bCPAP, F&P Healthcare, Auckland, New Zealand). Since then, CPAP has been used either after extubation, or as a primary mode of respiratory support, in babies with respiratory distress
syndrome (RDS) who exhibit sufficient respiratory drive.2
CPAP can be delivered using various devices. These devices can be broadly grouped
into continuous flow and variable flow systems. bCPAP and ventilator-derived CPAP
are continuous flow systems. Variable flow devices include the infant flow driver (IFD,
Infant flow nCPAP system, Care Fusion, Yorba Linda, CA), Benveniste gas jet valve
CPAP, Aladdin, and Arabella systems. The use of CPAP augments breathing and gas
exchange and decreases the risk of ventilator-induced lung injury (VILI). However, its
success is dependent on intact respiratory drive and lung disease that is not severe
enough to warrant mechanical ventilation.2
PHYSIOLOGIC BASIS OF BUBBLE CONTINUOUS POSITIVE AIRWAY PRESSURE
bCPAP uses air or blended gas that is heated and humidified and then delivered
to the infant through a low-resistance nasal prong, mask, or cannula. The distal
end of the expiratory tubing is submersed underwater, and the CPAP pressure
generated is equal to the depth of submersion. Varying the depth of the underwater expiratory tube thus varies the CPAP pressure (Fig. 1). The generation of
bubbling in the water chamber by exhaled gas has been hypothesized to produce
chest vibrations that may enhance gas exchange.4 With this principle, bCPAP may
be an effective and inexpensive option for providing respiratory support to premature infants.
One of the mechanisms of bCPAP is the generation of bubbles by the gas
escaping the submersed expiratory tube. The applied gas flow rate has been
observed to affect the degree of bubbling, and it has been suggested that oscillations
from bubbling affect the pressure amplitude and contribute to gas exchange by delivering low-amplitude, high-frequency oscillations to the lungs.5
Lee and colleagues6 tested the hypothesis that bCPAP contributes to gas exchange.
In a randomized crossover trial, they enrolled 10 preterm babies ready for extubation to
bCPAP or ventilator-derived CPAP. They reported a 39% reduction in minute volume
(P<.001) and a 7% reduction in respiratory rate (P 5 .004) with no change in transcutaneous CO2 or pulse oximetry during bCPAP. The calculation of minute ventilation in this
study has been questioned, but the study concluded that chest vibrations produced by
bCPAP might have contributed to improved gas exchange.
Morley and colleagues7 challenged the findings of Lee in a crossover trial of 27 preterm babies (median gestational age 27 weeks) at a bCPAP pressure of 6 cm H2O. They
observed a median (interquartile range) pressure amplitude of 2.7 cm H2O (2.54.0) for
slow bubbling (flow of 3 L/min) and 6 cm H2O (4.67.1) for vigorous, high-amplitude
bubbling (flow of 6 L/min). They also reported slightly lower pressure with slow bubbling
compared with vigorous bubbling (5.28 vs 5.98 cm H2O; P<.001) (Fig. 2). In this study,
they did not find any effect of bubbling on respiratory rate or minute ventilation.
Fig. 2. Effect of flow on bubbling (slow and vigorous). (From Morley CJ, Lau R, De Paoli A,
et al. Nasal continuous positive airway pressure: does bubbling improve gas exchange? Arch
Dis Child Fetal Neonatal Ed 2005;90:F3434; with permission.)
649
650
that condensate in the exhalation limb of the patient circuit during bCPAP could significantly increase pressure delivered to the patient. Hence, emptying fluid from the
exhalation limb every 2 to 3 hours is a good practice.
Components of the bCPAP circuit can also affect amplitude and frequency of noise,
which in turn can impact lung recruitment. Wu and colleagues19 reported that
increasing the size and submersion depth of the expiratory limb of a CPAP circuit
and decreasing the diameter of the bubble generator bottle intensified the magnitude
but diminished the frequency of noise transmitted to a lung model.
bCPAP applies small-amplitude, high-frequency oscillations in airway pressure
(Delta Paw). The increase in Delta Paw could affect the degree of respiratory support.
Diblasi and colleagues20,21 modified the bubbler exit angle and compared it at 135
(high-amplitude bCPAP) versus 0 (low-amplitude bCPAP). In this animal study, they
observed that PaO2 levels were higher (P<.007) with higher amplitudes, and that
PaCO2 levels did not differ (P 5 .073).
FACTORS AFFECTING THE SUCCESS OF BUBBLE CONTINUOUS POSITIVE AIRWAY
PRESSURE
Good nursing care is the mainstay of success, particularly in infants requiring prolonged support with bCPAP. A nasal injury scoring system (Table 1) to document
integrity of skin, septum, and other anatomic structures is helpful. Monitoring every
4 to 6 hours and early intervention are the most important variables. Strategies to minimize injury include use of protective barriers such as cannulaide or lyofoam, and
alternating the use of prongs and masks may also attenuate injury.
Fixation of the Nasal Interface
651
652
Table 1
Nasal injury scoring chart
Date/Time of Observation
Tip of nose
0:
1:
2:
3:
4:
Normal
Red
Red 1 indent
Red/indent/skin breakdown
As above 1 tissue loss
Nasal septum
0:
1:
2:
3:
4:
Normal
Red
Red 1 indent
Red/indent/skin breakdown
As above 1 tissue loss
Nostrils
0:
1:
2:
3:
4:
Normal
Enlarged
Enlarged and prong shape
Red, bleeding
As above 1 skin breakdown
Nose shape
0: Normal
1: Pushed up/back but normal
2: Pushed up and shortened. No normal
orientation when prongs removed
Data from Alsop E, Cook J, Gupta S. Nasal Injuries in Preterm Infants: Comparison of the Infant Flow
Driver to Bubble CPAP. E-PAS 2008: 4456.4
bCPAP systems work on the continuous flow principle. If the baby stops breathing
or the nasal interface is blocked or displaced, bubbling will cease. There is no provision on currently available systems for alarms. Intermittent checks and documentation of system performance are mandatory. Some commercially available
systems have a built-in mechanism to allow water to decant into the attached
container if the level rises above the set reference mark. If indigenous systems
are used, regular decanting and changing of water are essential to prevent inadvertent high CPAP and the risk of infection. There is also the provision of measuring
pressure close to mouth in the commercial systems for more precise monitoring.
Regular suctioning of the nasal passages and cleaning of the prongs also
contribute to good practice.
Optimizing Continuous Positive Airway Pressure Delivery
Unlike variable flow CPAP, where the pressures are delivered primarily at the nasal
interface, bCPAP delivery depends on the baby breathing through the submersed
expiratory tubing. If the babys mouth is open, the flow can leak, causing a drop in
pressure. To limit this, a pacifier or a chin strap can be used. Closure of mouth has
been demonstrated to increase the pressure in the pharynx by 2 to 3 cm H2O22
(Fig. 3). Regular aspiration of air from the stomach through an indwelling nasogastric
tube and leaving the nasogastric tube to vent are routine practices to avoid inadvertent
gastric distension.
Weaning from Bubble Continuous Positive Airway Pressure
The commonly used methods are pressure weaning and seesaw weaning. To use
either method, the baby should be stable on CPAP support with no significant apnea
Fig. 3. Set pressure versus pharyngeal pressure in passive and closed mouth positions. ((Top)
From De Paoli AG, Lau R, Davis PG, et al. Pharyngeal pressure in preterm infants receiving nasal
continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 2005;90:F7981; with
permission. (Bottom) Courtesy of Neotech Products, Valencia, CA; with permission.)
The clinical and hemodynamic criteria are commonly used to declare failure of CPAP
or to escalate the level of CPAP support. If a baby develops frequent minor apnea
(>1 per hour, of self-recovering desaturation or bradycardia) or an episode of major
apnea requiring intervention, support should be escalated.24 Increasing oxygen
653
654
Mazzella and colleagues29 compared IFD CPAP with bi-nasal prongs and bCPAP
through a single nasopharyngeal tube. They randomized 36 preterm infants
less than 36 weeks gestation at less than 12 hours of age to receive one of
the CPAP methods. They reported a significant beneficial effect on both oxygen
requirement and respiratory rate (P<.0001) with IFD CPAP, compared to bCPAP,
and a trend toward a decreased need for mechanical ventilation. This study, however,
was limited by a small sample size and the use of different nasal interfaces.
McEvoy and colleagues30 randomized 53 spontaneously breathing preterm babies
between 25 and 32 weeks gestation to receive either bCPAP or ventilator-derived
CPAP using Hudson prongs after initial stabilization. The respiratory measurements
(FRC and compliance) and CPAP failure through 7 days were compared. They
observed no differences between groups.
Tagare and colleagues31 compared the efficacy and safety of bCPAP with
ventilator-derived CPAP in preterm neonates with RDS. Babies with a SilvermanAnderson score greater than or equal to 4 and oxygen requirement greater than
30% within first 6 hours of life were randomly allocated to bCPAP or ventilatorderived CPAP, and the proportion of neonates succeeding was compared. A higher
percentage of infants was successfully treated with bCPAP (83% vs 63%, P 5 .03),
suggesting superiority of bCPAP for this indication.
In a prospective randomized clinical trial performed by Hosseini and colleagues,32 161
preterm infants (2837 weeks of gestational age) with RDS were randomized in the first
hour of life to bCPAP or MediJet system CPAP (Med-CPAP). Short bi-nasal prongs were
used in both groups and CPAP was set at 5 to 6 cm H2O. The primary outcome was duration of CPAP support. There was no difference between the 2 systems.
Yagui and colleagues33 compared bCPAP and IFD CPAP in 40 babies with birth
weight greater than 1500 g. They reported no differences between the groups with regard to demographic data and CPAP failure (21.1% and 20.0% for IFD CPAP and
bCPAP, respectively; P 5 1.000).
Mazmanyan and colleagues34 randomized 125 infants less than 37 weeks gestation
to bCPAP or IFD CPAP after stabilization at birth in a resource-poor setting. They reported bCPAP equivalent to IFD CPAP in the total number of days CPAP was required,
within a margin of 2 days. The results of this trial should be interpreted with caution in
extremely to moderately premature babies, because the study group was more
mature, but it is a reassuring finding for a population of larger babies in a developing
country. The median days (range) for days on CPAP were 0.8 days (0.0417.5) on
bCPAP, and 0.5 days (0.045.3) on IFD CPAP.
The trial by Bhatti and colleagues35 compared Jet-CPAP (variable flow) and bCPAP
in 170 preterm newborns less than 34 weeks gestation with the onset of respiratory
distress within 6 hours of birth. CPAP failure rates within 72 hours were similar (29%
vs 21%; relative risk 1.4 [0.82.3], P 5 .25). Mean (95% confidence intervals [CI])
time to CPAP failure was 59 hours (5464) in the Jet-CPAP group compared with
65 hours (6268) in the bCPAP group. In this well designed trial, no difference was reported between the 2 study devices; however, the investigators did not stratify babies
by severity of respiratory illness or gestational age.
bCPAP was compared with nasal BiPAP (Bilevel positive airway pressure) by
Sadeghnia and colleagues36 in a randomized controlled trial in 70 very-low-birthweight babies. They reported no difference in the average duration of noninvasive
respiratory support, complications of prematurity (such as chronic lung disease,
intraventricular hemorrhage, death, and the number of doses of surfactant), as
well as the duration of supplementary oxygen.
Randomized trials of continuous positive airway pressure after extubation
In a study by Sun and colleagues37 among babies greater than 30 weeks gestation
and birth weight greater than 1250 g, the results favored IFD CPAP over ventilatorderived CPAP. In another study, Stefanescu and colleagues examined 162 extremely
low birth weight infants and compared IFD CPAP with ventilator-derived CPAP using
INCA prongs. They did not find any difference in the extubation success rate between
the 2 study groups.38
These trials did not stratify babies by duration of ventilation. It has been reported
that nCPAP support has advantages over just supplemental oxygen if the duration
of ventilation is less than or equal to 14 days. The demographic differences in the
aforementioned trials make it difficult to draw conclusions, but the results suggest
that IFD CPAP is either superior to or has similar efficacy to ventilator-derived CPAP
when used after extubation. De Paoli and colleagues39 have stressed in their metaanalysis that a comparable nasal interface is required to allow comparison of CPAP
generation systems in randomized trials.
In a subsequent trial, Gupta and colleagues40 randomized 140 preterm infants 24 to
29 weeks gestation or 600 to 1500 g at birth to receive bCPAP or IFD CPAP following
655
656
the first attempt at extubation. Infants were stratified according to duration of initial
ventilation (14 days or >14 days). Babies were extubated when they passed the minute ventilation test used to objectively assess readiness for extubation.41 The primary
outcome of the study was the need for reintubation within72 hours. If an infant required
reintubation, the originally assigned CPAP device was used until the infant was no
longer requiring respiratory support. Although there was no statistically significant difference in the extubation failure rate (16.9% on bCPAP, 27.5% on IFD CPAP) for the
entire study group, the median duration of CPAP support was 50% shorter in the infants on bCPAP, median 2 days (95% CI, 13 days) on bCPAP versus 4 days (95% CI,
26 days) on IFD CPAP (P 5 .031). In infants ventilated for less than or equal to 14 days
(n 5 127), the extubation failure rate was significantly lower with bCPAP (14.1%; 9/64)
compared to IFD CPAP (28.6%; 18/63) (P 5 .046).
This well designed clinical trial suggests the superiority of post-extubation bCPAP
over IFD CPAP in preterm babies less than 30 weeks, who are initially ventilated
for less than 14 days. In this trial, similar nasal interfaces were used, stratification by
duration of ventilation was performed, a similar weaning approach was utilized, and
enrollment occurred after an objective assessment for readiness for extubation.
SUMMARY
nCPAP is increasingly used for respiratory support in preterm babies at birth and after
extubation from mechanical ventilation. Various CPAP devices are available that can
be broadly split into continuous flow and variable flow. There are potential physiologic
differences between systems, and the choice of a CPAP device is too often guided by
individual experience and preference rather than by evidence. When interpreting the
evidence, clinicians should take into account the pressure generation sources, nasal
interface, and the factors affecting the delivery of pressure, such as mouth position
and respiratory drive. With increasing use of these devices, better monitoring techniques are required to assess the efficacy and early recognition of babies who are
failing and in need of escalated support.
bCPAP seems to have physiologic properties that could facilitate gas exchange.
The evidence from studies suggests it is comparable to continuous or variable flow
CPAP for management of RDS at birth, even in resource-poor settings. bCPAP seems
to have better success when used post-extubation among infants who received ventilation for up to 14 days. Care and familiarity with CPAP further increases the likelihood
of success. Further work on minimizing nasal injuries and optimizing support will be
foci of further investigation.
REFERENCES
1. Gregory GA, Kitterman JA, Phibbs RH, et al. Treatment of the idiopathic
respiratory-distress syndrome with continuous positive airway pressure. N Engl
J Med 1971;284:133340.
2. Gupta S, Donn SM. Continuous positive airway pressure: physiology and comparison of devices. Semin Fetal Neonatal Med 2016;21(3):20411.
3. De Paoli AG, Morley C, Davis PG. Nasal CPAP for neonates: what do we know in
2003? Arch Dis Child Fetal Neonatal Ed 2003;88:F16872.
4. Martin S, Duke T, Davis P. Efficacy and safety of bubble CPAP in neonatal care in
low and middle income countries: a systematic review. Arch Dis Child Fetal
Neonatal Ed 2014;99:F495504.
5. Poli JA, Richardson CP, DiBlasi RM. Volume oscillations delivered to a lung model
using 4 different bubble CPAP systems. Respir Care 2015;60:37181.
6. Lee KS, Dunn MS, Fenwick M, et al. A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway
pressure in premature neonates ready for extubation. Biol Neonate 1998;73:
6975.
7. Morley CJ, Lau R, De Paoli A, et al. Nasal continuous positive airway pressure:
does bubbling improve gas exchange? Arch Dis Child Fetal Neonatal Ed 2005;
90:F3434.
8. Pillow JJ, Travadi JN. Bubble CPAP: is the noise important? An in vitro study.
Pediatr Res 2005;57:82630.
9. Pillow JJ, Hillman N, Moss TJ, et al. Bubble continuous positive airway pressure
enhances lung volume and gas exchange in preterm lambs. Am J Respir Crit
Care Med 2007;176:639.
10. Wu CS, Chou HC, Huang LT, et al. Bubble CPAP support after discontinuation of
mechanical ventilation protects rat lungs with ventilator-induced lung injury.
Respiration 2016;91:1719.
11. Bailes SA, Firestone KS, Dunn DK, et al. Evaluating the effect of flow and interface
type on pressures delivered with bubble CPAP in a simulated model. Respir Care
2016;61:3339.
12. Murki S, Das RK, Sharma D, et al. A fixed flow is more effective than titrated flow
during bubble nasal CPAP for respiratory distress in preterm neonates. Front
Pediatr 2015;3:81.
13. Roberts CT, Kortekaas R, Dawson JA, et al. The effects of non-invasive respiratory support on oropharyngeal temperature and humidity: a neonatal manikin
study. Arch Dis Child Fetal Neonatal Ed 2016;101:F24852.
14. Tyagi P, Gupta N, Jain A, et al. Intra-gastric pressures in neonates receiving bubble CPAP. Indian J Pediatr 2015;82:1315.
15. Davis P, Davies M, Faber B. A randomised controlled trial of two methods of
delivering nasal continuous positive airway pressure after extubation to infants
weighing less than 1000 g: binasal (Hudson) versus single nasal prongs. Arch
Dis Child Fetal Neonatal Ed 2001;85:F825.
16. Bushell T, McHugh C, Meyer MP. A comparison of two nasal continuous positive
airway pressure interfacesa randomized crossover study. J Neonatal Perinatal
Med 2013;6:539.
17. Kieran EA, Twomey AR, Molloy EJ, et al. Randomized trial of prongs or mask for
nasal continuous positive airway pressure in preterm infants. Pediatrics 2012;
130:e11706.
18. Youngquist TM, Richardson CP, Diblasi RM. Effects of condensate in the exhalation limb of neonatal circuits on airway pressure during bubble CPAP. Respir Care
2013;58:18406.
19. Wu CS, Lee CM, Yuh YS, et al. Influence of changing the diameter of the bubble
generator bottle and expiratory limb on bubble CPAP: an in vitro study. Pediatr
Neonatol 2012;53:35965.
20. Diblasi RM, Zignego JC, Smith CV, et al. Effective gas exchange in paralyzed
juvenile rabbits using simple, inexpensive respiratory support devices. Pediatr
Res 2010;68:52630.
21. Diblasi RM, Zignego JC, Tang DM, et al. Noninvasive respiratory support of
juvenile rabbits by high-amplitude bubble continuous positive airway pressure.
Pediatr Res 2010;67:6249.
22. De Paoli AG, Lau R, Davis PG, et al. Pharyngeal pressure in preterm infants
receiving nasal continuous positive airway pressure. Arch Dis Child Fetal
Neonatal Ed 2005;90:F7981.
657
658
23. Todd DA, Wright A, Broom M, et al. Methods of weaning preterm babies
<30 weeks gestation off CPAP: a multicentre randomised controlled trial. Arch
Dis Child Fetal Neonatal Ed 2012;97:F23640.
24. Davis PG, Morley CJ, Owen LS. Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal
intermittent positive pressure ventilation. Semin Fetal Neonatal Med 2009;14:
1420.
25. Sandri F, Plavka R, Simeoni U. The CURPAP study: an international randomized
controlled trial to evaluate the efficacy of combining prophylactic surfactant
and early nasal continuous positive airway pressure in very preterm infants.
Neonatology 2008;94:602.
26. Narendran V, Donovan EF, Hoath SB, et al. Early bubble CPAP and outcomes in
ELBW preterm infants. J Perinatol 2003;23:1959.
27. Pelligra P, Abdellatif M, Lee SK. Comparison of clinical outcomes between two
modes of CPAP delivery: underwater bubble versus conventional ventilatorderived. E-PAS 2006;59:475.
28. Massaro AN, Abdel-Haq I, Aly HZ. Underwater seal bubble CPAP versus
ventilator-derived CPAP: does mode of delivery make a difference in clinical
outcome? PAS 2005;57:2053.
29. Mazzella M, Bellini C, Calevo MG, et al. A randomised control study comparing
the Infant Flow Driver with nasal continuous positive airway pressure in preterm
infants. Arch Dis Child Fetal Neonatal Ed 2001;85:F8690.
30. McEvoy CT, Colaizy T, Crichton C, et al. Randomized trial of early bubble continuous positive airway pressure (BCPAP) versus conventional CPAP (CCPAP):
effect on pulmonary function in preterm infants. PAS 2004;55:2988.
31. Tagare A, Kadam S, Vaidya U, et al. Bubble CPAP versus ventilator CPAP in
preterm neonates with early onset respiratory distressa randomized controlled
trial. J Trop Pediatr 2013;59:1139.
32. Hosseini MB, Heidarzadeh M, Balila M, et al. Randomized controlled trial of two
methods of nasal continuous positive airway pressure (N-CPAP) in preterm infants with respiratory distress syndrome: underwater bubbly CPAP vs. Medijet
system device. Turk J Pediatr 2012;54:63240.
33. Yagui AC, Vale LA, Haddad LB, et al. Bubble CPAP versus CPAP with variable
flow in newborns with respiratory distress: a randomized controlled trial.
J Pediatr (Rio J) 2011;87:499504.
34. Mazmanyan P, Mellor K, Dore CJ, et al. A randomised controlled trial of flow driver
and bubble continuous positive airway pressure in preterm infants in a resourcelimited setting. Arch Dis Child Fetal Neonatal Ed 2016;101:F1620.
35. Bhatti A, Khan J, Murki S, et al. Nasal Jet-CPAP (variable flow) versus BubbleCPAP in preterm infants with respiratory distress: an open label, randomized
controlled trial. J Perinatol 2015;35:93540.
36. Sadeghnia A, Barekateyn B, Badiei Z, et al. Analysis and comparison of the
effects of N-BiPAP and Bubble-CPAP in treatment of preterm newborns with
the weight of below 1500 grams affiliated with respiratory distress syndrome:
a randomised clinical trial. Adv Biomed Res 2016;5:3.
37. Sun SC, Tien HC, Banabas S. Randomise controlled trial of two methods of nasal
CPAP (NCPAP): flow driver vs onventional CPAP [abstract 1898]. Pediatr Res
1999;45:322A, 1999.vvbb.
38. Stefanescu BM, Murphy WP, Hansell BJ, et al. A randomized, controlled trial
comparing two different continuous positive airway pressure systems for the
659