HƯỚNG DẪN SỬ DỤNG OXY LIỆU PHÁP CPAP CHO TRẺ EM

Original CPAP – Gregory 1970sNow CEO computer company Photo courtesy of Dr... Original CPAP – Gregory 1970sPhD Photo courtesy of Dr... What does CPAP offer?• Improves lung volume - tran

CPAP: Physiological basis for use in

Neonatal Practice Pros and Cons

Gugu KaliStellenbosch University/Tygerberg Hospital

Cape TownSouth Africa

Nil

George Gregory – 1960s anaesthetist

Pres Kennedy’s son – died of RDS 1963

Discovery why babies grunt

V Harrison et al Grunting = auto-PEEP

Pediatrics 1968; 41:3 549-559

Gregory 1970s

Original CPAP – Gregory 1970s

Now CEO computer company

Photo courtesy of Dr George Gregory.

Pediatric Anesthesia 23 (2013)

Original CPAP – Gregory 1970s

PhD

Photo courtesy of Dr George Gregory.

Pediatric Anesthesia 23 (2013)

However, CPAP went out of fashion for some time

In, out & back into fashion (> 1995)

TBH: DR THOM - CPAP

• MV   mortality, BPD, neurodevelopmental impairment

• Non-invasive support

• Gentler transition from birth DRICU  NICU

◦ transpulmonary pressure  prevent lung fluid back to alveoli

◦ lung aeration triggers PBF at birth & ventilation

Hospital-specific rates of CLD as defined by proportion who require supplemental oxygen at

36 weeks' PMA, stratified by birth weight, gestational age, and ethnicity.

Van Marter L J et al Pediatrics 2000;105:1194-1201

©2000 by American Academy of Pediatrics

CPAP vs MV

Avery 1987 – CPAP unit <BPD

Pediatrics 1987;79;26

What does CPAP offer?

• Improves lung volume - transpulmonary pressure and FRC

• Prevents alveolar collapse

• Improves oxygenation

• Decreases WOB

• Lowers Respiratory rate

What does CPAP offer?

• Splints the upper airway

• Improves thoraco-abdominal synchrony by increasing chest wall stability

• CPAP provokes the Hering-Breuer inflation reflex – which regulates duration of inspiration and expiration

• Stimulates lung growth

Morley CJ N Engl J Med 2008;358:700-8

Pfister R Clin Perinatol 39 (2012) 459–481

Rojas-Reyes MX Cochrane Database Syst Rev 2012 Mar 14;3:CD000510

• Diseases with low FRC, e.g RDS, TTN

• Apnea and bradycardia of prematurity

• Meconium aspiration syndrome (MAS)

• Airway closure disease, e.g BPD

• Tracheomalacia

• Partial paralysis of diaphragm

• Respiratory support after extubation

DEVICES

DR: Providing breathing support

DR: Providing breathing support

NeoTee®

Infant flow driver

Infant Flow generator

SiPAP / CPAP

Simple “TBH” CPAP

 length/width of prongs, mask sizes

 variable flow & pressure

 effective humidification of gas

 ability to monitor O2 concentration

• Staff training most important

Optimal PEEP??

• 5cmH2O appears to be safe

• 5-8cmH2O used in different settings

 no difference in cardiac output (J Pediatr 2014;164:726-9)

• More air leaks with 8cmH2O in 1 study (COIN)

(N Engl J Med 2008;358:700-8)

• Nasal obstruction – secretions, improper application of prongs

• Gastric distension – swallowed air

• Air leakage (pressure loss) – usually during acute phase

• Pneumothorax

• Nasal trauma

 erosion/necrosis of septum (prongs)

 junction nasal septum & philtrum/colummela (mask)

 equal frequency

(Kieran E, Ped 2012; Yong SC, Arch 2005)

Nasal irritation & septal damage

USE THE BIGGEST PRONGS THAT COMFORTABLY

FIT THE NOSTRILS TO AVOID LOSS OF PRESSURE

AND AVOID SEPTAL DAMAGE

Key factors for success

• nCPAP device

• early management in delivery room and on admission to neonatal unit

• oxygen saturation limits

• minimal handling and positioning

• early nutrition

• high quality basic nursing and medical care

Thomson MA, Respiratory Therapy 2006

When to wean?

• No tachypneoa or retraction

• No apneoa and bradycardia

• FiO2 usually room air

TBH EXPERIENCE

J Trop Pediatr 2003

Use of nasal CPAP in extreme preterm infants with no access to neonatal intensive care

Prospective RCT at TBCH

Conclusion:

nCPAP significantly improved short-term survival of VLBW infants with moderate

to severe respiratory distress syndrome

Pieper et al Journal of Tropical Ped, Vol 49, No 3 2003

Delivery room CPAP

(2004)

ALL viable Premature

babies:-• Assess breathing whilst applying immediate Facial

CPAP with appropriate mask connected to a T-piece system (NeoPuff or other)

• Facial CPAP 5 (-7 ) cmH2O

• No positive pressure if breathing acceptable and pulse rate > 100/min

• Connect SpO2 (Saturation monitor)

• Continue facial CPAP during transfer to nursery

Short term outcome (survival to discharge from TBCH) of a retrospective cohort of ELBW infants receiving continuous distending pressure from birth and NCPAP in the nursery in TBCH between 1/1/06-30/6/06

Conclusion:

81% of infants 800 - 1000 g survived in level 2 ward in TBCH

Mean birth weight (g) 830

Mean gestational age 27.9 weeks

Hospital stay in TBCH 25.7 days

Data presented at the 2006 research day of the University of Stellenbosch

> 2006

Delivery room CPAP

ALL viable premature

babies:-• Assess breathing whilst applying immediate Facial CPAP with appropriate mask connected to a T-piece system (NeoPuff or other)

• Facial CPAP 5 (-7 ) cmH2O

• No positive pressure if breathing acceptable and pulse rate > 100/min

• Connect SpO2 (Saturation monitor)

• Continue Facial CPAP during transfer to nursery

• Start CPAP with infant flow driver in nursery

• If FiO2 > 0.3 – 0.35 administer surfactant (1-2 hours of life)

Modified INSURE (No sedation)

“In-out”

Who did not fare that well?

Semin Neonatol 2002

67%

ELBW survival rates at TBCH

Therapy Formula

HBO

+ NCPAP(IFD)

+ ANS EBM / KMC

DR CPAP

NW nCPAP

+In-out Surfactant

Survival

%

Predicting failure

• GA, BWT

• Gender (male)

• Male, ≤800g (<750g, TBH), Fi O2 > 0.25  failure (De Jaegere, Acta 2012)

• SMT – stable microbubble test on gastric aspirate

(Bhatia R, Neonatology 2013)

◦ within 1 st hour

◦ ≥ 8/mm 2 predicts CPAP success

◦ > specificity than shake test

• Can save lives

• Improves outcomes in ELBW

• Inexpensive

• Can be done in non-intesive ward

(with proper ongoing training)

• Expertise & outcomes improve with time (TBH experience; Aly H, Ped 2004)

530g 680g

Profile from our nursery

THANK YOU