DC/DC Converter 24V/90W User Guide - CPAP Masks, CPAP Machines
What Type of CPAP and Why - Nationwide Children's Hospital
Transcript of What Type of CPAP and Why - Nationwide Children's Hospital
What Type of CPAP and Why
Brandon Kuehne MBA/RRT-NPS, RPFTErin Wishloff BS/RRT-NPS
Neonatal Respiratory ServicesNationwide Children’s Hospital
Columbus, Ohio2011
Disclosures The Planning Committee and Faculty of
this activity have no disclosed conflicts of interest related to this content.
No commercial support was received for this program
Completion Criteria: In order to receive Continuing Nursing Education (CNE) credit, you must attend 80% of the program.
Agenda
Discuss indications for CPAP / Bi-LevelDiscuss various CPAP / Bi-Level devicesReview ventilators which are approved to
provide NCPAPDescribe available interface devices Finally discuss latest evidence-based
literature of NCPAP
Why use CPAP? Recruitment
Atelectasis Maintenance of FRC
Post extubation Apnea of prematurity RDS
Structural Tracheal malacia
Chest wall stability
To treat an ↑’d WOB
Poor gas exchange
Alternative to intubation
↓ CLD (VON)
↓ VAP
VON Collaborative(As part of an initiative to ↓incidence of BPD)
Looked @ 3 arms activated in D.R.1. Intubate, administer surfactant, remain intubated
2. CPAP, surfactant if indicated, CPAP
3. Intubate, administer surfactant, rapidly extubate to CPAP
– Phase III of collaborative finished for (Small Baby Guidelines) #3 had best patient outcome Primary goal to reduce CLD
– Bubble CPAP chosen method
??? Bubble CPAP ???
Successfully used by Dr. Wung
30+ years Extremely low incidence of BPD/CLD from his
facility
Devices Bubble CPAP
Requirements • Air/O2 proportioner (Blender)• Water column• Modified ventilator circuit (Factory setup
available)
Benefits• Potential for:
Gas exchange due to bubbling• Not easily reproduced
Bubble CPAP Benefits (Cont.)
Relatively inexpensive • Minimal upfront money• Modification of your
current vent circuit
Multiple interface devices available
• Cover a wide range of patients
• Hudson RCI• F&P
Bubble CPAP
Disadvantages
No built in monitors (F&P)• High Pressure / Δ pressure• Disconnect• Apnea
Potential for ↑ WOB Water vs. Tubing depth (25% Acetic Acid)
• Between caregivers
Bubble CPAP Disadvantages
With excessive flow rates a greater than intended peep has been measured at patient.
(M. Wald ET AL., 2010) To create the constant PEEP of 6 with a flow of 4 L/min during
Bubble-CPAP ventilation, the shaft of the underwater seal was adjusted accurately at 6 cm below the waterline.
However, at a flow rate of 10 L/min, the shaft of the underwater seal had to be adjusted at 4 cm below the waterline for creating the correct PEEP of 6.
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CF-NCPAP Continuous Flow NCPAP
One of the earliest types of CPAP used• (ET CPAP was earlier)
Prongs connected between the inspiratory and expiratory limb of ventilator
CPAP set by adjusting PEEP and flow
Standard to which many other new CPAP devices are tested against
CF-NCPAP
Advantages Used for past 35+ years = Literature High comfort level with caregivers
Disadvantages Much better options available Proven inferior
NIPPVNon-Invasive Positive Pressure Ventilation
orNasal Intermittent Positive Pressure Ventilation
Two levels of pressure delivered via ventilator using short bi-nasal prongs or nasopharyngeal prongs.
• Can be achieved with either:• PS/CPAP• Set rate, PIP and PEEP
NIPPV
Potential Benefits Reduction in apnea frequency ↑ CO2 removal Lung recruitment Synchrony may ↓ WOB Use of current facility equipment
NIPPV
Disadvantages Dedicates expensive equipment Potential for:
Dysynchrony due to Trigger: Trigger determined by:
• Leak• Lack of proximal flow measurement (flow probe)
VF-NCPAP
Variable Flow Nasal Continuous Positive Airway Pressure
orFluidic Flip Continuous Positive Airway
Pressure
Comprised of:• An Infant flow generator• An infant flow driver
VF-NCPAP The Generator:
Directs flow toward the patient during inhalation. Then diverts flow away from the patient during exhalation. (The Flip)
How Does It Work?
CPAP pressure is determined by the flow to the generator and prongs or mask
© 2010 CareFusion Corporation or one of its subsidiaries. All rights
reserved.
VF-NCPAP
Expiration (Viasys generator)
Driver flow + Exhaled patient gas.
Patient
Exha
led
patie
nt g
as
VF-NCPAP
Exhalation:
During exhalation the gas flow is directed away from the patient.
Set pressure is maintained during expiratory phase.
VF-CPAP
Advantages Free standing system Internal monitors Safety dump valve ↓ WOB vs. CF-NCPAP Better delivery of pressure (prescribed) Better synchrony
Disadvantages Up front cost Proprietary circuit
I like the idea of variable flow, but I also like the idea of NIPPV because I like the idea of two pressures. Is there anything else I can use?
What is SiPAP?
SiPAP is a CPAP/Bi-Level device.
That is, it is capable of functioning as a straight forward VF-NCPAP machine. It can also function as a Bi-Level device providing two separate pressures to the patient.
Very similar to APRV or IMV-Pressure control (of sorts, let me explain)
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cmH2O
BiPhasic Strategy BiPhasic mode: Cycles between high/low CPAP levels on timed
basis Intermittent increase in CPAP pressure by 2-3 cmH20 for a
duration up to 3.0 seconds to produce a “Sigh breath” Each “Sigh” can augment lung volume by 3-6 ml/kg and unload
work of breathing Enables the infant to breathe spontaneously throughout the
cycle at either pressure.
© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved.
Pandit. Pediatric, 2001; 108 (3):682-685
SiPAP Currently uses VF-NCPAP interface device Ability to set two pressures
Baseline (CPAP) = Low Pressure Upper Pressure = High Pressure (CPAP to 11cmH2O)
Set I-time during high pressure (0.1 – 3.0 sec) Rate Independent Flow set for low and then above low for high
pressure Alarms
Apnea (Graseby capsule placed on abdomen)Once again, Think Infant Star -StarSync
Pressure (+3/-2 cm H2O) FiO2 (± 5%)
SiPAP
Advantages May stimulate respiratory center
• ↓ # of apneic periods
With both pressures set leads to an ↑ MAP• Improved oxygenation
Provides lung recruitment• as one looks to move, further, or stand-up the
hysteresis curve – what?
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CPAP Pressure
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l/kg)
Carefusion Corp.
Hysteresis Curve(CPAP should provide a better relationship between
pressure and volume)This is the point from which you want the baby to start breathing; the steeper part of the curve. More Vt for pressure
SiPAP
Disadvantages Potential for hypocarbia Standard learning curve issues – Per the FDA it is a
bi-level cpap device; not a ventilator. (but it sure looks and acts like one)
Not currently synchronized - SNIPPV option not commercially available in U.S.
Airlife™ nCPAP System
Potential Benefits Longer anatomically correct - Articulating
silicone Prongs Deeper articulating silicone mask Easily applied fixation device
Potential disadvantages Headgear required Pressure on lip of patients < 1000g Bending/occlusion of prongs
Complications common to all
Septal Breakdown Labor intensive (Sicker patients now on
CPAP)Dry mucosaCPAP Belly Atelectasis due to pressure lossDilated naresDevelopmental delays due to mobility Positioning difficulties
Nationwide Children’s NICU
Patients < 34 weeks and < 2500 grams should be treated with bubble nCPAP Some patients < 34 weeks gestation may not
tolerate bubble nCPAP and may need to be switched to variable flow nCPAP
Patients < 1250 grams should be treated with bubble nCPAP, unless otherwise ordered by the attending neonatologist
Nationwide Children’s NICU
Patients ≥ 34 weeks and ≥ 2500 grams should be treated with variable flow nCPAP Bubble nCPAP is not well tolerated or
applied effectively to older and larger patients mainly due to patients displaying greater mobility.
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Evidence based rationale for using bubble NCPAP for premature baby population
Via head-to-head comparison of bNCPAP vs. infant flow systems (variable flow)
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A Randomized Controlled Trial of Post-extubation Bubble ContinuousPositive Airway Pressure Versus Infant Flow Driver Continuous PositiveAirway Pressure in Preterm Infants with Respiratory Distress Syndrome
SAMIR GUPTA, MD, SUNIL K. SINHA, MD, PHD, WIN TIN, MD, AND STEVEN M. DONN, MD
(J Pediatr 2009;154:645-50)
Gupta cont.
Objective:
To compare the efficacy and safety of bubble continuous positive airway pressure (CPAP) and Infant Flow Driver (IFD) CPAP for the post-extubation management of preterm infants
with respiratory distress syndrome (RDS)
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Gupta cont.
Study design:
A total of 140 preterm infants at 24 to 29 weeks’ gestation or with a birth weight of 600 to 1500 g who were ventilated at birth for RDS were randomized to receive either IFD CPAP (a variable-flow device) or bubble CPAP (a continuous-flow device). A standardized protocol was used for extubation and CPAP. No crossover was allowed. The primary outcome was successful extubation maintained for at least 72 hours.
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Gupta cont.
Results:
Seventy-one infants were randomized to bubble CPAP, and 69 were randomized to IFD CPAP. Mean gestational age and birth weight were similar in the 2 groups, as were the proportions of infants who achieved successful extubation for 72 hours and for 7 days.
The median duration of CPAP support was 50% shorter in the infants on bubble CPAP. Moreover, in the subsetof infants who were ventilated for less than 14 days, the infants on bubble CPAP had a significantly lower extubation failure rate.
There was no difference in the incidence of chronic lung disease or other complications between the 2 study groups
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Conclusions:
Bubble CPAP is as effective as IFD CPAP in the post-extubation management of infants with RDS; however, in infants ventilated for < 14 days, bubble CPAP is associated with a significantly higher rate of successful extubation.
Bubble CPAP also is associated with a significantly reduced duration of CPAP support.
NCPAP vs. Bi-level NCPAPNasal continuous positive airway pressure (CPAP) versus bi-level nasal CPAP in preterm
babies with respiratory distress syndrome: a randomized control trial
Gianluca Lista, Francesca Castoldi, Paola Fontana, Irene Daniele, Francesco Cavigioli, Samantha Rossi,
Diego Mancuso, Roberta Reali(Arch Dis Child Fetal Neonatal ED 2010;95:F85-F89)
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Lista cont.
Objective:
To compare the clinical course and outcome of RDS infants managed with bi-level nasal cpap versus nasal cpap.
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Lista cont.
Study Design:
A total of 40 RDS infants with a GA 28-34 weeks were randomized to either a NCPAP of 6cm H20 or a bi-level NCPAP of pressure low 4.5 and pressure high 8 cm H20.
Infant Flow Driver used in both arms.
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NCPAP vs. Bi-level Mode
Outcome Infant Flow Bi-level
Days of respiratory support 6.2 days 3.8 daysDays on oxygen 13.8 days 6.5 daysGestational age at discharge 36.7 wks 35.6 wks
Conclusion:“Bi-level nCPAP was associated with better respiratory outcomes versus nCPAP, and allowed earlier discharge.”
Lista G, et al. Arch Dis Child Fetal Neonatal Ed. 2010 Mar;95
© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved.60
Results:
NCPAP vs. Bi-level NCPAP
Nasal Bilevel vs. Continuous Positive Airway Pressure in Preterm Infants
Claudio Migliori, Mario Motta, Agnese Angeli, and Gaetano Chirico (Pediatric Pulmonology, 2005 40:426-430)
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© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved. 62
Study Design:
20 infants 24-31 weeks (mean 29.6 wks)
Infants evaluated during a 4 hour period; alternating nCPAP and biphasic ventilation phases lasting 1 hour each
Settings
NCPAP• 4-6 cmH2O
Biphasic• Rate of 30• Time high 0.5 seconds• Pressure high 4 cmH2O above NCPAP pressure
Migliori et al, Pediatric Pulmonology.2005: 40:426 – 430
Migliori cont.
Results:
All patients completed the study without need for reintubation. For the two Biphasic periods, a significant increase in Pa02 and decrease in PaC02 was noted compared with the NCPAP periods.
No cardiovascular differences were noted during any of the phases.
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Migliori cont.
NCPAP vs. Bi-level NCPAP
Conclusion:
Biphasic mode associated with…
Significant increase in peripheral oxygen saturation and transcutaneous PaO2
Significant reduction in transcutaneous PaCO2
Reduction in respiratory rate
Improvement in heart rate and blood pressure
© 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved. 64
Nasal intermittent postivie pressure ventilation in the newborn: a review of literature and evidence-based guidelines.
V Bhandari (2010)
Literature review of SNIPPV and its us as1. Primary Mode- referring to its use soon after birth2. Secondary Mode- referring to its use after a longer period from > 2hr to days or
weeks.
Studies using SNIPPV as primary mode have shown: Decrease in duration of oxygen use in SNIPPV vs. CV. Decrease incidence in BPD when comparing SNIPPV vs. NCPAP.
Studies using SNIPPV as secondary mode have shown: SNIPPV to be significantly better then NCPAP in preventing extubation failure. SNIPPV infants to have decreased need for supplemental oxygen and
decreased BPD compared to NCPAP infants.
Kuehne 2009 65