Lung Injury Prevention :

Early CPAP
Risma Kerina Kaban
Gendis Ayu Ardias
Neonatology Division
Departement of Child Health University of Indonesia
Cipto Mangunkusumo Hospital

OBJECTIVES

Incidence of BPD and severe BPD

CPAP: How does it works?
Indication of CPAP
Contraindication of CPAP
Weaning and CPAP Failure
Recommendation role of CPAP in RDS
Does the use of Nasal CPAP soon after
birth prevent chronic lung disease
(CLD)?

Bancalari, E. 2011. THE THOMAS E. CONE, Jr, MD LECTURE ON PERINATAL HISTORY: The
Evolution of Bronchopulmonary Dysplasia and Mechanical Ventilation. Diakses di:
https://www2.aap.org/sections/perinatal/presentations/BPD-Bancalari-2011.pdf.

Incidence Bronchopulmonary
Displasia (BPD) & Severe BPD

The incidence of having BPD

remained
constant
after
controlling for gestational age
(GA) (12 %). However, the odds
of having severe BPD declined on
everage 11 % per year between
1994 and 2002.

Unadjusted annual rates for GA

<29 weeks

Smith, et al. J. Pediatr. April 2005: 146(4): 469 - 473

Anadjusted annual rates for GA

2933

Smith et al, J Pediatrics, April 2005:146;469-473

 BPD remains a cost of serious

morbidity in surviving preterm infant.
Prophylactic or early nCPAP are
suggested to:
a. minimized the incidence of BPD
b. minimized the need for intubation
and
ventilation
c. reduction in surfactant usage
d. reduction number of days
ventilated

Characteristics of the
preterm airway

Disadvantages of the preterm

infant
Decreased lung compliance
Less surfactant and of less quality
More water content
Ineffective inspiration
Instability of the thorax and extrathoracic
airway
Horizontal ribs and small area of
apposition of the diaphragm
Difficulty to maintain the lung volume
Small lung volume
Lung volume depends on expiratory time
High thorax compliance
Less laryngeal tonus for closure of the

In CPAP : How does it

work ?
Distension of the airways

Decrease of airway resistance

Ventilation
Increase in tidal volume
Decrease in work of breathing
Avoidance of obstructive apnoea
Improvement of laryngo-/tracheomalacia

Effects on the alveoli

Increase in alveolar diameter
Alveolar recruitment

oxygenation

Reopening and
Stabilizing of alveoli

Alveolar diameter

Better surfactant
metabolism

Lung compliance

Tidal volume

CO2-elimination

RFC
Total alveolar surface

Intrapulmonary shunts

Work of breathing

Oxygenation

CPAP INDICATIONS
Preterm neonates with Respiratory
Distress Syndrome (RDS)
Apnea of prematurity
Neonates who are weaning from a
mechanical ventilator
Alternative to mechanical
ventilation / surfactant

CONTRAINDICATIONS OF NASAL
CPAP

Diaphragmatic Hernia
No Spontaneous breathing
Atresia Choana
Fistula Tracheosophagus

Hazards of CPAP
Pulmonary over distension
airleaks
Gastric distension
Nasal excoriation, cartilage injury,
septal distortion, facial injury
Renal failure
Intracranial pressure IVH

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)

SETTING OF CPAP
1. CPAP should Commence at 5-7
cm of water, it may inccreased
at the discretion of the
consultant
2. FiO2 40-60 % or base on
saturation target (88% - 92%)
3. Flow 6-8 L/ min for preterm
infants , 8-10 L/ min for term
infant

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 of 5 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 1224 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.

CPAP Failure

Neonates on nasal CPAP of 7-8 cm

H2O will need mechanical
ventilation if any of the following
occurs:
FiO2 on nasal CPAP >40%
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

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.

Early NCPAP for ELBW

Hany Aly et al. Pediatrics 2004

Role of CPAP in Management of RDS

Recommendations
CPAP should be started from birth in all babies at risk of
RDS, such as those <30 weeks gestation who do not
need MV, until their clinical status can be assessed (D).
Short binasal prongs should be used rather than a single
prong as they reduce the need for intubation and a

pressure of at least 5 cm H2O should be applied (A).

The use of CPAP with early rescue surfactant should be
considered in babies with RDS in order to reduce the
need for MV (A).

N-CPAP as Alternative to
IPPV
Prophylactic N-CPAP- No Surfactant :
N-CPAP used in all infants at risk for
developng respiratory failure
Prophylactic N-CPAP After Early
Surfactant : N-CPAP post short intubation
and surfactant administration, INSURE.
Early N-CPAP: N-CPAP used as treatment
for a specific respiratory failure criteria
Rescue N-CPAP : N-CPAP used as treatment
for specific criteria (FiO2 > 40 %)

Early vs delayed N-CPAP

Ho JJ, Henderson-Smart DJ, Davis PG. 2010. Early versus delayed initiation of continuous distending
pressure for respiratory distress syndrome in preterm infants. Available at: http://www.thecochranelibrary.com.
(Review)

Early Application of CDP (Continuous Distending

Pressure) or CPAP Reduces Subsequent Use of
IPPV

This studies were done in the in 1970

& 1980, in the era of no antenatal
steroid and early surfactant
administration
Limitations from the studies :
Numbers of infants was small
The mean age ranged from 7 to 18
hours old when CDP was applied

Does The Use Nasal

CPAP soon After Birth
prevent CLD ?

Is Chronic Lung Disease Preventable

A Survey of Eight Centers ?

Avery ME, et al, Pediatrics 79 :26-30,1986

Colombia Group (Center 3) Had

Lowest Problem of CLD :

Early nasal prong CPAP of 5 soon

after birth , BW = 500 1500 g
Limited use of intubation and MV
PaCO2 value was allowed to go as
high as 60 mmHg reduces
amount of mechanical ventilation
lessen barotrauma

Does variation in respiratory management in

NICUs explain differences in CLD?

Compared Columbia NY with 2 Boston hospitals.

Infants < 1501 gr in 1991-1993
Boston Columbia
n=341 n=100
Ventilation 75%29%
Surfactant 45%10%
Oxygen at 36 wks 22%4%
Van Marter. Pediatrics 2000, 105,1194-1201

Does The Experience With The

Use of NCPAP Improve Over Time
Retrospective analysis
Command early NCPAP in the
delivery room, BW < 1000 gr
Reduction in BPD rates and an
increase in average weight gain.

Hany Aly et al. 2004. Does the Experience With the Use of Nasal Continuous Positive Airway
Pressure Improve Over Time in Extremely Low Birth Weight Infants. Pediatrics: 114.

Does The Experience With The

Use of NCPAP Improve Over Time

Hany Aly et al. 2004. Does the Experience With the Use of Nasal Continuous Positive Airway
Pressure Improve Over Time in Extremely Low Birth Weight Infants. Pediatrics: 114.

Can N-CPAP be started in

the delivery room as an
alternative to surfactant
and mechanical
ventilation?

Distribution of infants (%) into respiratory

care groups by birth weights

Adapted from Ammari et al. J Pediatr. 2005; 147(3):341-347

Prophylactic vs Rescue Nasal CPAP:

Multicenter randomised controlled trial
230 infants, GA 28-31 weeks
Prophylactic : CPAP within 30 minutes
after birth
Rescue : CPAP if FiO2 > 40%
Mechanical ventilation / surfactant if
O2>40% for >30 minutes
More than 80% of both group received
prenatal
steroid
Sandri et al, Archieves Diseases Childhood 2004

Results : No differences
Prophylactic CPAP Rescue CPAP
Need for
Surfactant
Mechanica
l
Ventilation
BPD
Air leaks

22,6%

21,7%

12,2%

12,2%

1,7%

0,9%

2,6%

2,6%

Sandri et al, Archieves Diseases Childhood 2004

 In a newborn of 28-31 weeks

gestation, there is no greater benefit
in giving prophylactic n-CPAP then in
starting n-CPAP when the oxygen
requirement increases to a FiO2> 0,4

Sandri et al, Archieves Diseases Childhood 2004

Prophylactic CPAP vs control, Outcome 01 Use of IPPV

Subramaniam P, Henderson-Smart DJ, Davis PG

 Should surfactant be administrated

in combination with n-CPAP?
- failure of early n-CPAP can be a
result of
surfactant deficiency in extremely
preterm infants
- prophylactic administration of
surfactant
increase of successful
management
with early n-CPAP

Surfactant and N-CPAP for Newborns

with RDS
RDS infants 25-35 wks on nasal CPAP allocated to
intubation + surfactant or continue on CPAP
Surfactant (35) CPAP(33)
Gestation
30
29
Age at entry (hrs)
13
10
Needed IPPV
43%
85%*
Days O2
6
6
Death by 28 days
6%
15%
Oxygen @28 days
9%
9%
* P<0,003
Verder et al NEJM 1994

Nasal CPAP or intubation at Birth

for Very Preterm Infants
610 infants born at 25-28 weeks,
ramdomly assigned at 5 minutes
after birth to :
CPAP 8 cmH2O
or
Intubation and ventilation
Outcomes Death or BPD assessed at
28 days, 36 weeks and at discharge
Morley CJ et al. NEJM 2008; 358 (7) : 700-708

Nasal CPAP or Intubation at Birth

______________________________________________________________________

Death or need for Oxygen Treatment or Respiratory Support at 28

days

______________________________________________________________________

Outcome

All infants (25-28 wks gestation)

______________________________________________________________________

(N=307)

CPAP
(N=303)

Intubation Odds Ratio

(95% Cl)

Death, O2 or respiratory
support at 28d (%)

64,4

75,6
(0,41-0,83)

Death before 28 days (%)

5,2
5,0
(0,51-2,18)

0,58

10,6

______________________________________________________________________
Morley CJ et al. NEJM 2008; 358 (7): 700-708

Nasal CPAP or Intubation at Birth

______________________________________________________________________
Death or need for Oxygen Treatment or Respiratory Support at 28
days
______________________________________________________________________
Outcome 25 or 26 wks gestation
27 or 28 wks gestation
______________________________________________________________________
CPAP

Intubation

Death, O2 or
respiratory
support at
28d (%)

Odds ratio

89,0
94,3
(0,17-1,39)

Death before 11 5,7

2,04
28 days (%)
(0,72-5,74)

CPAP

Intubation

0,49
52,4
(0,39-0,86)

Odds ratio
65,7

0,58

2,4 4,5
0,52
(0,17-1,58)

______________________________________________________________________
Morley CJ et al. NEJM 2008; 358 (7): 700-708

Nasal CPAP or Intubation at Birth

______________________________________________________________________

Death or need for Oxygen Treatment or Respiratory Support at 36

weeks
______________________________________________________________________

Outcome

All infants (25-28 wks gestation)

______________________________________________________________________

(N=307)

CPAP
(N=303)

Intubation Odds Ratio

(95% Cl)

Death, O2 treatment or
respiratory support (%)

35,2

Death before 36 wks

gestation (%)

6,5

40,3
0,81
(0,58-1,12)
5,9

1,10
(0,57-2,12)

______________________________________________________________________
Morley CJ et al. NEJM 2008; 358 (7): 700-708

Nasal CPAP or Intubation at Birth

______________________________________________________________________
Comparisons of Secondary Outcomes
______________________________________________________________________
CPAP
Intubation
(N=303)
(N=303)
P Value
Surfactat treatment (%)

38

77

<0,001

Methylxantine treatment (%)

84

71

<0,001

Days any respiratory

support (median)

26

0,24

Days on ventilation (median)

Days on CPAP (median)

16

0,81

Days on oxygen (median)

21

13
42

49

<0,001

0,07

Discharge home on oxygen (%)

7,6
9,5
0,46
______________________________________________________________________

Nasal CPAP or Intubation at Birth

______________________________________________________________________

Comparisons of Secondary Outcomes

______________________________________________________________________

CPAP Intubation
(N=303) (N=303) P Value
Days in any hospital (no.)
Pneumothorax
PIE (%)

74 79 0,09

9,1 3,0 0,001

5,5 3,6 0,33

IVH grade 3 or 4 (%) 8,9 9,3 0,89

Cystic PVL (%)

2,9 4,0 0,51

______________________________________________________________________
Morley CJ et al. NEJM 2008; 358 (7): 700-708

Prophylactic N-CPAP
There is currently insufficient
evidence to assess the benefits and
risks of profilactic n-CPAP in the
preterm infant .

Ho JJ, Henderson-Smart DJ, Davis PG. 2010. Early versus delayed

initiation of continuous distending pressure for respiratory distress
syndrome in preterm infants (Review).

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

CONCLUSIONS
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
Early CPAP is effective to prevent lung injury
and reduce the incidence of BPD
CPAP is effective after extubation to prevent
respiratory deterioration
Short binasal prongs more effective than
single or long prongs
There is no clear evidence that early CPAP
instead of IPPV improves long term outcome

CASE STUDY

kasus

Bayi lahir dengan UG 25-26

mg,lahir s.c atas indikasi PEB &
asma, BL: 640 gr, A/S: 5/7/9
Orang tua hanya mau
menggunakan CPAP, tidak mau
intubasi karena alasan biaya.

 Bayi diberikan CPAP 7 sejak lahir , FiO2 30%

- SaO2 : 88 93 %
- HR
: 140-150 x/menit, RR: 70 x/menit
- Suhu 36.9 C
- AGD setelah CPAP : pH
: 7.3
[CO2 -] : 48.9 mmHg
[HCO3 -] : 25.4 mmHg
BE
: 0.9
Diagnosa: - NKB SMK
- Respiratory Distress e.c HMD

 Rontgen Thorax setelah CPAP: HMD grade II

Usia 2 jam:
- SaO2 60%, FiO2 100%
- PEEP 8 FiO2 40%
- Surfaktan tidak diberikan
karena orang tua menolak
intubasi karena alasan biaya

Usia 9 hari:
Pasien sesak dilakukan intubasi (mendapat
tanggungan biaya dari kantor orang tua)
PEEP 9
FiO2 80% , SaO2 90%
AGD:
pH
: 7.15
[PCO2 -] : 70.4 mmHg
[PO2 ]

: 34.9 mmHg

[HCO3 -]

: 22.3 mmHg

BE
Hb

: -10
: 9.6 mg/dl

Bayi diintubasi

kasus II

Rontgen Thorax usia 28 hari:

Kesan: BPD

 Diagnosa: - NKB SMK

- HMD
- BPD
- PDA besar perbaikan.

Take home messsages

Bila bayi prematur mengalami distress
pernapasan pada saat lahir berikanlah
CPAP dengan PEEP 7& FiO2 sesuai dengan
target saturasi.
Bila CPAP gagal (CPAP 7 & FiO2 > 30-40%)
lakukan intubasi & berikan surfaktan
Sebaiknya surfaktan diberikan < 2 jam
(early rescue treatment) untuk
mendapatkan hasil yang lebih baik

Thank You