CPAP: Physiological basis for use in Neonatal Practice Pros and Cons Gugu Kali Stellenbosch University/Tygerberg Hospital Cape Town South Africa Disclosure Nil Overview • Historical background • Physiological basis/rationale for use • Indications • Devices • Complications • TBH experience • Summary George Gregory – 1960s anaesthetist Pres Kennedy’s son – died of RDS 1963 Discovery why babies grunt V Harrison et al Pediatrics 1968; 41:3 549-559 Grunting = auto-PEEP Gregory 1970s • Saved prem’s life with CPAP • Post CPAP – 80% survival 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 CPAP: In, out & back into fashion (> 1995) TBH: DR THOM - CPAP 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 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 (-7 ) cmH2O • No positive pressure if breathing acceptable and pulse rate > 100/min • Connect SpO2 (Saturation monitor) • Continue facial CPAP during transfer to nursery Admission to nursery • Start peripheral infusion with 10% dextrose-containing solution (Neolyte / Neonatalyte) • No invasive monitoring • Non-invasive BP monitoring • SpO2 88 – 93% • ABG not done routinely - decisions based on clinical assessment if < 1000g or ≤ 28 weeks’ gestation • If > 1500 g and / or > 30 weeks’ gestation, intubation and ventilation if CPAP fails 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 Number of infants 81 Survival (%) 60 Mean birth weight (g) 830 Mean gestational age 27.9 weeks Conclusion: Hospital stay in TBCH 25.7 days 81% of infants 800 - 1000 g survived in level ward in TBCH Data presented at the 2006 research day of the University of Stellenbosch > 2006 “InSurE” • Intubation Surfactant Extubation onto CPAP OR • In-Out Surfactant 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 (-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 < 1994 1994 2004 > 2007 Therapy Formula HBO + NCPAP (IFD) + ANS EBM / KMC DR CPAP NW nCPAP + In-out Surfactant Survival % 20 45 62 74.8 Predicting failure • GA, BWT • Gender (male) • Male, ≤800g ( 0.25  failure (De Jaegere, Acta 2012) • SMT – stable microbubble test on gastric aspirate (Bhatia R, Neonatology 2013) ◦ within 1st hour ◦ ≥ 8/mm2 predicts CPAP success ◦ > specificity than shake test SUMMARY • 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) 680g 530g Profile from our nursery 530g 580g THANK YOU ... Saved prem’s life with CPAP • Post CPAP – 80% survival Original CPAP – Gregory 1970s Now CEO computer company Photo courtesy of Dr George Gregory Pediatric Anesthesia 23 (2013) Original CPAP –... ventilation CPAP vs MV 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 Avery 1987 – CPAP. .. Gregory Pediatric Anesthesia 23 (2013) However, CPAP went out of fashion for some time CPAP: In, out & back into fashion (> 1995) TBH: DR THOM - CPAP >2000 • MV   mortality, BPD, neurodevelopmental