CPAP

CPAP and PEEP

CPAP refers to a positive pressure
applied to the airways of a
spontaneously breathing baby
throughout the respiratory cycle.

PEEP refers to the positive pressure

applied to a mechanically ventilated
neonate during the expiratory phase
of respiration.
 History
• Use of CPAP began in 1970s as the
missing link between supplemental
oxygen and mechanical ventilation.
• During the 1980s & early 1990s CPAP fell
out of favor as it was believed to cause
increased incidence of air leaks, gastric
distension, damage due to hard nasal
prongs.
• Resurgence in interest in late 90s.
 Benefits of Using NPPV Compared
to Invasive Ventilation
• Avoids the trauma associated with intubation and
the complications associated with artificial airways

• Reduces the risk of ventilator associated

pneumonia (VAP)

• Reduces the risk of ventilator induced lung injury

associated with high ventilating pressures
 Contd…
• Provides ventilatory assistance with greater
comfort, convenience and less cost than
invasive ventilation

• Reduces requirements for heavy sedation

Physiology
How can CPAP or PEEP help the baby
with a respiratory problem?
• It reduces upper airway occlusion by
decreasing upper airway resistance and
increasing the pharyngeal cross sectional
area.
• It reduces obstructive apnoeas.
• It increases the FRC.
• It increases the compliance and tidal
volume of stiff lungs with a low FRC by
stabilising the chest wall and
counteracting the paradoxical movements
• It reduces inspiratory resistance by dilating
the airways. This permits a larger tidal
volume for a given pressure, so reducing
the work of breathing.
• It regularises and slows the respiratory rate.
• It conserves surfactant on the alveolar
surface.
• It diminishes alveolar oedema.
• Nasal CPAP after extubation reduces the
proportion of babies requiring reventilation.
 Optimal lung inflation.
• Defined as the lung volume at which the
recruitable lung is open but not
over-inflated.

• CPAP is one method which best achieves

optimal lung inflation with resultant good
oxygenation and ventilation and hopefully
less CLD.
 Methods of generating CPAP
Continuous flow CPAP Variable flow CPAP

• It consists of gas flow • It generates CPAP at

generated at a source the airway proximal to
and directed against the infant’s nares.
the expiratory limb of
a circuit.
 Continuous flow CPAP
• In ventilator-derived CPAP, a variable
resistance in a valve is adjusted to provide
this resistance to flow.
• In bubble CPAP the distal end
of the expiratory tubing is
immersed under either 0.25% acetic acid
or sterile water to a specific depth to
provide the desired level of CPAP.
• Another continuous flow system is
Benveniste gas-jet valve.
 Variable flow CPAP
• These devices have dual injector jets
directed at each nasal prong in order to
maintain a constant pressure.

Patient nasal connection

Intra nasal pressure

monitoring
Fresh gas inlet

Interchangeable
Nasal prongs

Twin jet injector

Nozzles.

Expiratory channel
 Child’s
Connection to exhalation
Nasal prongs.

Fluidic flip of
Inspiratory
Gases.

• The major advantage of variable flow CPAP is reducing

the work breathing.
• In continuous flow CPAP, during exhalation infant must
exhale against the flow of incoming air.
• The fluidic flip of variable flow devices assists exhalation.
• Additionally the variable flow devices
appear to be able to maintain a more
uniform pressure level compared to
continuous-flow CPAP.

• The most commonly used variable-flow

system is the Infant flow driver (IFD).
 Devices through which CPAP is provided.

• Nasal devices
Prongs
Types- short – 6-15mm (nasal prongs)
long – 40-90mm (nasopharyngeal prongs)
Nasal cannula
Nasal masks
• Face masks
• Head box with nasal seal
• Endotracheal tubes.
WHICH NASAL CPAP DEVICE SHOULD
BE USED?

• Nasal and nasopharyngeal prongs remain

the most common method of
administering CPAP in neonates.

• Devices in common use for the delivery of

nasal CPAP include single and double
(binasal) prongs, in both short (nasal) and
long (nasopharyngeal) forms.
 Types of prongs

• Argyle

• Hudson

• Inca

• Fisher & Paykel

• EME
• Nasopharyngeal
 Single versus double prong devices
• The evidence, from a meta-analysis of randomised
clinical trials of nasal CPAP devices in very preterm
neonates, is that short binasal devices are more
effective at preventing re-intubation when compared
with single nasal prong devices. A randomised trial
in more mature preterm infants with early
respiratory distress reported better oxygenation,
respiratory rate, and weaning success with a short
binasal device when compared with single prong
nasopharyngeal CPAP.
 Which short binasal prongs should be
used?
•There are. several short binasal prongs
available to the clinician, including the
Argyle prong, Hudson prong, infant flow
driver (IFD), and INCA prongs.

•Studies using lung models suggested that

the prototype IFD, compared with Argyle
prongs and Hudson prongs, generated
more stable pressures.
 Can nasal cannulae be used to
deliver nasal CPAP?
• Nasal cannulae are used to deliver oxygen
into the nose at low flow, usually with no
intention of generating positive pressures
in the airway. However nasal cannulae,
with an outer diameter of 3 mm and flows
up to 2 l/min, have been reported to
deliver CPAP. A study of CPAP via nasal
cannulae found it as effective in the
treatment of apnoea of prematurity as
conventional CPAP prongs.
 HOW SHOULD NASAL CPAP
DEVICES BE FIXED?
There are many different techniques for
fixing the devices to the infant. The exact
technique does not matter as long as the
device is secure and not traumatising the
nose, face, or head. More research is
needed to define the least traumatic nasal
device and method of fixation.
 IS MOUTH CLOSURE
IMPORTANT?

?
When NCPAP or
NPCPAP are applied,
there often is enough
downward pressure on
the palate, providing a
natural seal so that there
is minimal to no
pressure loss through
the mouth.
 ET CPAP
Disadvantages
• Increased resistance
• Increased dead space
• Requires invasive intubation
Bubble nasal CPAP
Bubble CPAP Delivery System
Oscillations from the
bubbling reverberated
back into the infant's
airway and it is
speculated that the
observed vibrations
enhance gas exchange
 Is bubble CPAP superior to
conventional CPAP?
• Few randomised studies have compared these
two approaches, but those that have (Colaizy, 2004;
McEvoy, 2004; Lee, 1998) have recorded reductions of
up to 50% in the need for mechanical ventilation
in favour of bubble CPAP.
• Another advantage is low cost: bubble CPAP
equipment costs are 15% of those for
mechanical ventilation, and the technique can
be administered by nursing staff.
An indigenous bubble CPAP
 An indigenously developed low cost
device is certainly welcome but not at
the cost of compromised safety and
potential harm.
 Primary uses of CPAP
Disorders in which use of CPAP has
been studied in RCTs are
2. Treatment of apnea of prematurity,
3. In Post-extubation management
following mechanical ventilation,
4. Early management of RDS.
 Apnea of prematurity
• Because longer episodes of apnea frequently
involve an obstructive component, CPAP
appears to be effective by splinting the upper
airway with positive pressure and decreasing the
risk of pharyngeal or laryngeal obstruction.
• CPAP probably also benefits apnoea by
increasing functional residual capacity (FRC)
and so improving oxygenation status.
• It has been shown that at higher FRC, time from
cessation of breathing to desaturation and
resultant bradycardia is prolonged.
However, the Cochrane review regarding
CPAP use for AOP concludes that this
area needs additional evaluation.
 Post-extubation management
following mechanical ventilation
The Cochrane Collaboration review
concluded: “Nasal CPAP is effective in
preventing failure of extubation and
reducing oxygen use at 28 days of life in
preterm infants following a period of
endotracheal intubation and IPPV.”
 NCPAP as primary therapy for RDS

• If a preterm baby with RDS is spontaneously

breathing well enough to maintain adequate
heart rate, but with distress (manifested by some
combination of grunting, flaring and retraction),
mechanical ventilation with PEEP may be
indicated.
• Rather than immediately employing mechanical
ventilation, many neonatologists will strongly
consider the use of CPAP in this setting, usually
at a medium level of pressure.
In a survey of all 58 neonatal units with
intensive care cots in the Northern Region
of England it was found that briefly
intubating, giving surfactant, then starting
NCPAP (INSURE) is common in infants
with severe respiratory distress syndrome
and in very preterm infants. This is despite
scant evidence to date that the practice
decreases chronic lung disease or need
for mechanical ventilation.
• Sandri et al performed a RCT in 230 premature
infants (28-31wk) comparing prophylactic NCPAP
(within 30min of birth) to rescue NCPAP (once the
infants required an FiO2>40% to maintain SpO2
levels).

• There were no significant differences between

groups with regard to need for exogenous surfactant
or mechanical ventilation.

• Conclusions: In newborns of 28–31 weeks

gestation, there is no greater benefit in giving
prophylactic NCPAP than in starting NCPAP when
the oxygen requirement increases to a FIO2 > 0.4.
Other applications of CPAP in neonates

• MAS.
• Post-op respiratory management.
• Pulmonary edema.
• CHF.
• Laryngomalacia, tracheomalacia.
• PPHN.
• Pulmonary hemorrhage.
• Use of CPAP in delivery room.
 CPAP in delivery room
• If CPAP is chosen for use right after delivery,
there are several methods by which it can be
administered, including via face mask or nasal
prongs, and with the use of a bag or T- piece
resuscitator.
• The use of a T-piece resuscitator allows the
exact pressure to be easily set and maintained
at a desired CPAP level, as long as the delivery
device (prongs or mask) is properly set-up.
• CPAP cannot be administered with a self-
inflating bag.
 Success with NCPAP
NCPAP is successful when meticulous
attention is paid to both the infant and to
the NCPAP Delivery System. This involves
vigilance in:
• Monitoring the infant’s condition
• Maintaining an optimal airway
• Maintaining a patent CPAP delivery circuit
• Prevention of complications which may
arise from NCPAP
 Complications
• Malpositioned or displaced prongs.
• Obstruction by secretions.
• Local irritation and damage to nares and
septum. (good oral hygiene e.g. with lemon
glycerine swabs or saline should be considered
to prevent drying)
• Air trapping.
• Air leaks.
• Hypotension.
• Increased ICP
• Bowel distension (CPAP Belly)
CPAP
belly
Severe nasal snubbing

Columella necrosis (A)

Progressing to absent
Collumella at 3 months(B)
Progressive flaring of nostrils, circular distortion of nares
and flattening of alar ridges after prolonged flow
driver continuous positive airway pressure at three months.
 DOES NASAL CPAP INCREASE
THE RISK OF AIR LEAK?
• A randomised trial of early prophylactic
CPAP versus oxygen alone showed no
difference in the incidence of air leak.

• No results on the incidence of air leak are

yet available from randomised controlled
trials comparing early CPAP with
mechanical ventilation.
 Contraindications
• Infants who have progressive respiratory
failure and are unable to maintain
oxygenation, PCO2<60, pH>7.25.
• Certain cong. malformations
(diaphragmatic hernia, choanal atresia)
• Severe cardiovascular instability.
• Poor or unstable respiratory drive that is
not improved by CPAP.
Determining optimal levels of CPAP
• No simple and reliable method of finding the
optimal level has been found.
• If the infant has stiff lungs or low lung volumes,
increasing the distending pressure improves
oxygenation up to about 8 cm H2O.
• Increasing pressure increases carbon dioxide
retention, although often by not very much, so
there is a trade off between improving the
oxygenation and a rise in the carbon dioxide
concentration.
• The Cochrane review of nasal CPAP at
extubation suggested a level of 5 cm H2O
or more was more effective than lower
levels.
To determine the CPAP or PEEP pressure:
• Look at the chest X-ray picture. Do the lungs
look collapsed or oedematous, or well
expanded? High or low pressures may be
required depending on the problem.
• If oxygenation is the main problem increase the
distending pressure.
• If carbon dioxide retention is the main problem
reduce the distending pressure.
• Start at 4–5 cm H2O and gradually increase up
to 10 cm H2O to stabilise the oxygenation while
maintaining a pH > 7.25 and PaCO2 < 8.0 kPa.
 Weaning from CPAP
• The optimal method remains unanswered.
• Infants who require an FiO2>0.4 or are
clinically unstable are unlikely to be
successfully weaned off.
• Although some units try abrupt
discontinuation of NCPAP, most wean by
gradually decreasing either time spent on
CPAP or the CPAP pressure.
 What new things do we know about
nasal CPAP for neonates?
• Short double prongs are more effective than
single prongs for delivering nasal CPAP.

• Nasal CPAP is effective for the post-extubation

support of preterm infants.

• NIPPV is a useful method for augmenting nasal

CPAP.

• NCPAP can be used as primary treatment for

RDS.
 What questions remain?

• Does early nasal CPAP for RDS reduce mortality

and morbidity when compared with intubation for
very preterm neonates?

• Can more effective and less traumatic nasal CPAP

devices and methods of fixation be developed?

• What is the most effective source of pressure for

CPAP?

• What is the optimal pressure level and how can this

be judged?

• How should babies be weaned from CPAP?