Continuous Positive

Airway Pressure
(CPAP)

Risma Kerina Kaban

Rosalina D Roeslani
Neonatology Division
Dept of Child Health
Cipto Mangunkusumo
Hospital, Jakarta
 Definition of CPAP
Continuous positive airway pressure
(CPAP) is a device that maintains positive
pressure in the neonates airway during
spontaneous breathing.
A modality of respiratory support in which
increased pulmonary pressure is provided
artificially during expiratory phase of the
respiration in spontaneously breathing
neonate
 Historical review
Poulton & Oxam 1936
Gregory et all 1971: first trial
Agostino et al 1937: first RDS managed
with CPAP
Bubble & dual flow CPAP (Infant flow
drive)
 Types of CPAP
Bubble CPAP & Dual Flow
CPAP machine
Ventilator
 Various Modes of CPAP
Methods advantages disadvantages

ET tube Stable ++/good control & Invasive/airway resistance

ventilator access

Nasal prongs Easy/low resistance/easy Septal erosion/nasal

feeding/non invasive obstruction/abdominal
distension

Nasopharyngea Non invasive/easy feeding Leaks/pressure

l tube necrosis/abdominal
distension
 Physiological effect
Pulmonary : Benefit
Increases Functional Residual Capacity
(FRC)
Reduce work of breathing
Improve ventilation-perfusion mismatch
: increase oxygenation
Reduces upper airway obstruction
Conserves surfactant
Reduce obstructive apnea
 Physiological effect
Pulmonary : Risk
Air leak syndrome
Decreases compliance at high pressure
CNS: Risk
Increase Intracranial pressure
IVH
Renal: Risk
Increase ADH/aldosterone
Decrease urine output, renal failure
GIT:risk
abdominal distension
Indications of nasal CPAP

Preterm neonates with respiratory

distress syndrome (RDS)
Neonates with transient tachypnea of
the newborn (TTN)
Neonates with meconium aspiration
syndrome (MAS)
Neonates with frequent apnea and
bradycardia of prematurity
 Indications of nasal CPAP

Neonates with paralysis of the

diaphragm
Neonates who are weaning from a
mechanical ventilator
Neonates with airway diseases such
as tracheomalacia and bronchiolitis
Neonates after abdominal or chest
surgery
 Contraindications of
nasal CPAP
Diaphragmatic Hernia
No spontaneous breathing
Atresia choana
Fistula tracheoesophagus
 Benefits of CPAP
Reduction in need for endotracheal
intubation and ventilation
Reduction in duration of intubation and
ventilation
Reduction in need for additional doses of
surfactant
Reduction in supplemental oxygen
Reduction in risk for BPD
Reduction in costs
 Why CPAP?
CPAP may be associated with:
Less CLD
Less pneumonia
Less neuromorbidity
Less need for intubation
 Hazards of CPAP
Pulmonary over distension air leaks
Gastric distension
Nasal excoriation, cartilage injury, septal
distortion, facial injury
Renal failure
Intracranial pressure IVH
Water-Seal CPAP
 Components of CPAP- I
A circuit for continuous flow of
inspired gas
Source of O2 and compressed air provide the
inspired gas.
An O2 blender enables the appropriate FiO2 of
gas to be given.
A flow meter controls the rate of continuous
flow of the inspired gas (usually kept at 5-7
L/min).
A heated humidifier warms and humidifies the
inspired gas.
 Components of CPAP- II

A device to connect the circuit to the

neonates airway
For the purpose of this protocol nasal
prongs are the preferred method of
applying CPAP.
 Components of CPAP- III

A means of creating a positive

pressure in the circuit
Positive pressure in the circuit can be
achieved by immersion of the distal
expiratory tubing in 0.25% acetic acid
solution to the desired depth (5 cm) or
CPAP valve.
 Nasal CPAP
pressure bubble CPAP
generators conventional ventilator
infant flow driver
others

nasal prongs
unilateral (1-sided ) binasal (2-sided)prongs
endotracheal-tube
O2 nasal cannula (small diameters)
INCA /VESTA prongs (bigger diameter: short)
Argyle/Novametrix prongs (hard plastic: short)
Hudson prong
Nose-mask
others
Prongs and Tubes
Hudson Prongs
CPAP Nasal Prongs
 Nasal CPAP
Infant flow: prongs and mask

P.H.Dijk Beatrix Childrens Hospital UMCG

 Correct Prong Sizes
Size 1 for weight 700-1000 grams
Size 2 for weight 1000-2000 grams
Size 3 for weight 2000-3000 grams
Size 4 for weight 3000-4000 grams
Size 5 for weight > 4000 grams
 Correct
Correct Prong
Prong Sizes
Sizes
Use the size guide to measure for the
correct size prong or mask.
Does The Use Nasal CPAP
soon After Birth prevent
CLD ?
 Criteria for Starting
Nasal CPAP:
Early Nasal CPAP (ENCPAP):
Immediately after birth
BW < 1000 g (Hany Aly et al; 2004)
Gest age < 32 wks (Peter Dijk et al)
Respiratory distress (i.e. tachypnea, grunting,
flaring, retractions)
(Gittermann M.K. et al; 1997)
 Criteria for Starting
Nasal CPAP

Rescue Nasal CPAP:

FiO2 > 0,4 (40 %) 30 minutes and SpO2

93 % - 96 % (Sandri et al; 2004)
 Clinical Procedure
After Stabilization :
Start CPAP immediately after birth
Upon arrival from the delivery room
The neonate should be immediately weighed,
dried, and put under infant warmer
Pulse-oxymeter should be attached
(preferably in the right arm).
 clinical procedure
CPAP used for AOP is indicated after one
severe episode requiring bag and mask
ventilation
Recurrent minor apnoes may also be an
indication for CPAP although it is usual to
commence the infant on aminophylline IV
All infants on CPAP should have
indwelling size 8 Frenzh orogastric tube
 Setting of
SETTING OF CPAP
CPAP
1. CPAP should Commence at 5-7 cm
of water, it may inccreased at the
discretion of the consultant
2. FiO2 40-60 %
3. Flow 6-8 L/ min for preterm infants ,
8-10 L/ min for term infant
 Maintaining CPAP
Monitoring the Neonate on CPAP
The neonate on nasal CPAP should have the
following systems checked every 2-4 hours
Gastrointestinal: Observe for abdominal
distension, visible loops, and auscultate
bowel sounds
Keep CPAP prongs off the nasal
septum at all times
 maintaining CPAP
Suction nasal cavities, mouth , pharynx,
and stomach every 2-4 hours and, as
needed.

Increased respiratory efforts, increased need for O2

and episodes of apnea/bradycardia may be indications
for suction.
Use size 8 F for nasal suction. Note the amount,
consistency, and color of the secretion.
To loosen dry thick secretions, use a few drops of
sterile 0.9% saline solution.
 maintaining CPAP
Check the integrity of the entire CPAP
system.
Is the blender set at appropriate percentage?
Is the flow meter set between 5 and 7 liters/min?
Does the humidifier hold the correct amount of
water?
Is the inspired gas temperature appropriate?
Is the corrugated tubing empty of water?
Is the tip of the tubing in the outlet bottle at 5 cm
Is the outlet bottle bubbling?
 Feeding with CPAP
Nasal CPAP is not a contraindication to
enteric feeding.
It may be necessary to aspirate excess
air from the stomach before feeding.
If clinically stable, neonates on CPAP
can be fed by nipple, gavage, or
continuous feeding.
 Weaning off CPAP
After the CPAP is applied, neonates should
breathe easily with a noticeable decrease in
respiratory rate and retractions.

FiO2 should be lowered gradually in

decrements of 5% guided by the pulse-
oximeter reading or by blood gas results.

The requirement of FiO2 will come down to

room air.
 weaning off CPAP
If the neonate is breathing comfortably on
CPAP with FiO2 of 21%, he should be given a
trial off CPAP.

The neonate should be assessed during the

trial for any tachypnea, retractions, oxygen
desaturation, or apnea.

If any of these signs is observed the trial is

considered failed CPAP should be
restarted immediately at least a day before
another trial is attempted.
 weaning off CPAP

Weaning CPAP by 1-2 cm should be used

until 4-5 cmH2O. CPAP may be stopped
when it is tolerated for 12-24 hours

Reduction of pressure has priority over

reduction of inspired O2 concentration once
the FiO2 is < 40%. In general reduction of the
FiO2 should be by 5% at a time
 weaning off CPAP

Do not trade CPAP with FiO2

If there is any doubt of respiratory

compromise during the process of weaning,
do not wean the neonate.

It is wise to anticipate and prevent lung

collapse rather than manage already
collapsed lungs.
 Weaning CPAP
Cochrane review 2011 :
weaning pressure VS time of CPAP :
Pressured wean : less time in CPAP,shorter
duration of oxygen therapy, hospital stay
 CPAP Failure
Neonates on nasal CPAP of 5 cm H2O
will need mechanical ventilation if
any of the following occurs:

FiO2 on nasal CPAP >60%

paCO2 >60 mm Hg
Persistent metabolic acidosis with
base deficit of > -10
 CPAP failure

Marked retractions observed while on

CPAP
Frequent episodes of apnea and/or
bradycardia
 CPAP failure
During escalation of therapy
Very Low Birth Weight Infants
< 25 weeks GA
Very Hypoxic Infants
Severe RDS on Chest X-Ray
Infants with Need for Surfactant

During de-escalation of therapy

Weaning from mechanical ventilation
Fatigue
Apnea
Hypoxia
 CPAP failure

Before initiation of mechanical

ventilation check:
Is the CPAP system is intact and
attached to the neonates nose?
How does the neonate look clinically?
If s/he looks fine repeat the blood gas
to exclude any laboratory error.
 Troubleshooting
The bottle is not bubbling. This is due to
an air leak somewhere in the circuit.
Remove the prongs from the nose and
occlude them.

If the system bubbles, it means that you

are not using the correct size prongs or
they are not correctly curved down in the
nose or fitting snugly.
 Troubleshooting

Sometimes if the neonate simply opens

his/her mouth the system will stop
bubbling. This can be corrected by placing
a chin strip.
If the bottle does not bubble, it means the
problem is within the circuit. Systematically
check each component of the circuit.
 troubleshooting
The prongs do not stay in place.
Check for the following:

Are you using the right sized prongs?

Does the hat fit snugly?
Are the corrugated tubes fixed correctly to
the hat on both sides and at the correct
angle to the prongs?
Does the Velcro moustache need
replacement?
 troubleshooting

The neonate is not settling down:

Check for airway secretions.
Use a pacifier and swaddle the
neonate.
Aspirate excess gas from the
stomach, if necessary.
 troubleshooting
Nasal septum damage. Caused by
continuous pressure and/or friction on
the nasal septum. Prevention is a key
strategy:

Use the correct sized prongs.

Secure the prongs with fitted hat and correctly
position pins and rubber band on the
corrugated tubes.
Use a Velcro moustache.
 troubleshooting

Do not allow the bridge of the prongs to

touch the nasal septum at any time.
Use nasal cushion (douderm!)
Avoid twisting of the prongs. This can
cause lateral pressure against the septum.
 Evidence on clinical Use
Primary treatment of RDS
Early vs late:
The application of CPAP early in the
course of disease before alveolar collapse
accurs, better than late by: reducing lung
damage, promoting lung function &
surfactan pool
Early : reduction MV (RR 0,55 (95 %CI
0,32,0,96) NNT 6
No significant: BPD, death, pnemothorax
 Evidence on clinical Use
Delivery room,very early CPAP:
3 highly quality RCT : propylactic/DR
CPAP vs convensinal (intubation-
surfactant-MV) Gestation <28 week.
CPAP 50 % reduction in need for
intubation, MV & surfactant
Initial stabilization on CPAP on provision of
rescue surfactant should be the preferred
approach preterm G <28 w.
 Evidence on clinical Use
CPAP & surfactant InSure strategy)
Establishing & maintaining FRC
Meta-analysis : 6 trials
Reduction need of MV RR 0,51, 95% CI
0,57-0,79
Reduction BPD RR 0,51, 95 % CI 0,26-
0,99
But contribution of early surfactant in
decreasing the incidence of BPR remain
speculative
 Evidence on clinical Use
Verder, et all & reininger, et al: : CPAP
with surfactant, CPAP alone : decrease
MV (symptomatic preterm)
CURPAP trial, VON DRM trial:
prophylactic surfactant was not superior
to N CPAP & early rescue surfactant in
decreasing MV , death & BPD
 Evidence on clinical Use
AAP recommendation regarding the use
of prophylactic surfactant G < 30 w R
CPAP
Trend towards increased risk of BPD (RR
1,13; 95% CI 1,02-1,25)
2 trials: timing rescue surfactant &
CPAP G 27-33 W: 1-2 hours ( lesser
MV)
 Evidence on clinical Use
Important: COIN,SUPPORT,VON DRM
& CURPAP) G < 28 W, antenatal
steroid coverage >90 %
 Evidence on clinical Use
Post extubation
9 trials postextubation CPAP vs head box:
less incidence of apnea, acidosis
respiratory & increased oxygen need
Apnea of prematurity
CPAP with Methyl xanthine : no trial
Wide spread use
 Evidence on clinical Use
Other application:
Relieves sign of cardiac failure due to PDA
Pneumonia/TTN/post op, pulmonary edema
& hemorrhage
MAS : CPAP resolving atelectasis & due to
alveolar injury & surfactant deficiency. Murky
et al 75 % managed by CPAP alone
Laryngo/tracheo,bronchomalacia
 Conclusion
Conclusion
Oxygen therapy should be given with careful
monitoring of arterial oxygen tension or oxygen
saturation
CPAP increases FRC leading to improved
oxygenation and compliance
CPAP reduces the need of mechanical
ventilation and the incidence of CLD
The current CPAP system requires time and
experience to reach a satisfactory level of
success
 Conclusion
CPAP is effective in the management of RDS
and can be used starting in the delivery room
to avoid IPPV, mainly in larger infants over
26-27 wks
CPAP is effective after extubation to prevent
respiratory deterioration
CPAP reduces apnea
 Unanswered Questions
Pressure source : What is the most effective
system to deliver N CPAP?
What is the optimal pressure for each case?
What is the best time to initiate N CPAP and
for how long should be continued?
Is effective of CPAP related to gestational
age?
What are the long term advantage?
Are there non-respiratory consequences with
the use of N CPAP ?

Need More Multicentre Randomized Trials

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