Neonatal Cpap (Continuous Positive Airway Pressure) Updates 

What is CPAP?

CPAP is Continuous Positive Airway Pressure. It is not a ventilatory strategy. It refers to the application of positive pressure in the airway throughout the respiratory cycle in a spontaneously breathing patient. It is especially useful in patients where there is a tendency for alveolar collapse. CPAP improves oxygenation

1. Improves the Functional Residual Capacity (by alveolar recruitment)

2. V/Q Mismatch

Components of CPAP

1. Gas source O2 or blended air O2 
2. Pressure generators
   • Continuous flow devices: Desired CPAP is generated by obstruction to gas flow by a valve or water column. E.g.: Infant ventilators, Bubble CPAP
   • Variable flow devices: Variation in gas flow generates CPAP; E.g.: Infant flow driver (IFD), Viasys SiPAP
3. Interface patient delivery
   • Nasal prongs
   • Nasal masks
   • Nasal cannula
   • Nasopharyngeal prongs

Also read: Neonatal Respiratory Monitoring

Nasal Prongs-Types:

• Hudson prongs
• Argyle prong
• IFD 
• RAM Nasal Cannula

Nasal mask vs Nasal Prongs

Nasal masks have: Less injury, Less leakage, and less treatment failure than Nasal prongs

Bubble CPAP

Bubble CPAP is attached to the expiratory limb

Indications of CPAP in neonates

Common

• RDS
• AOP
• Post-extubation in preterm VLBW infants
• TTN

Others

• Pneumonia
• MAS
• Pulmonary edema or Pulmonary hemorrhage
• Laryngo/Tracheo/Bronchomalacia

Also read: Allergic Rhinitis in Children: Symptoms, Causes, Diagnosis 

Contraindications of CPAP in neonates

• Progressive respiratory failure with PaCO2 > 60 mm Hg PaO2 <50 mmHg
• Congenital Airway Malformations
  • CDH
  • TEF
  • Cleft palate
  • Choanal atresia
• Severe Cardio-respiratory instability (Hypotension)
• Poor respiratory drive, especially if not responding to CPAP

When to initiate CPAP?

Early

Putting the patient in CPAP <1-2 hours of distress. All preterm <32 weeks with respiratory distress. If 32-34 weeks gestation -> CPAP started if RR more than or equal to 70/min or Silvermann Anderson score at least 3-4

Prophylactic

CPAP before distress,Indicated in all preterm babies < 28 week gestation (Started in delivery Apnea of the prematurity room)

Monitoring on CPAP

• Vitals: HR, RR, SpO2
• Serial Downe's or Silverman Anderson scoring
• ABG
• Perfusion: CFT, BP, Peripheral pulses, Urine output
• Abdominal girth
• Nasal injury

Also read: Childhood Pneumonia- Causes, Symptoms, and Treatment

Targets during CPAP in Neonates

• SpO2: 90-95%
• PaO2: 50-70 mm Hg
• PaCO2: 40-50 mmHg

CPAP Protocols

RDS: Initiating parameters: 5-6 cm of H2O, FiO2:0.3-0.5(30-50%) . If no improvement: Increase pressure by 1 cm of H2O (1-2 cm), Maximum: up to 8 cm, Increase FiO2 by 0.05 (5%), Increase FiO2 by 0.05 (5%), maximum: up to 0.6 (60%)

Failure of CPAP: Worsening of distress despite CPAP: Silverman Anderson score shows PaO2

<50%, PaCO2> 60%. Delayed CPAP increases the risk of failure of CPAP. Weaning from CPAP

• Stable on CPAP → No distress (Normal SPO2 and Normal ABG)
• Reduce FiO2 by 0.05 to reach a value of 0.3
• Reduce pressure by 1 cm of saline every 24 hours till it reaches 4 cm of water

 (Pressure is more important.) Initiating parameters: 4 cm of H2O, FiO2 (0.21-0.4); decided by SpO2: If there is no improvement, increase the pressure to a maximum of 5 cm H2O, provided FiO2 is not increased . Failure of CPAP. Recurrent apnea needing PPV despite CPAP Weaning from CPAP: No apnea/Bradycardia for 12-24 hours. Method: Similar to RDS

CPAP Post-Extubation: Initiating parameters: 4-5 cm H2O, same FiO2 pre-intubation or 0.05 higher. If no improvement: increase the pressure and FiO2, similar to RDS. Failure of CPAP & Weaning from CPAP (Protocol similar to RDS)

Also read: Anatomy And Basics Of Pediatric Pulmonology

Hazards or Complications of CPAP

Irritation/Mucosal damage/Septal necrosis/Skin damage. Pulmonary air leaks: most severe. Pneumothorax (associated with high pressures). Decreased cardiac output, reduced venous return, less RV stroke volume, & altered LV distensibility. Decreased pulmonary blood flow with pulmonary resistance. Gastric distention and CPAP Belly Syndrome

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