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The Use of Bubble CPAP in Premature Infants: Local Experience

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The Use of Bubble CPAP in Premature Infants: Local Experience HK J Paediatr (new series) 2007;12:86-92 The Use of Bubble CPAP in Premature Infants: Local Experience KM CHAN, HB CHAN Abstract Bubble continuous positive airway pressure (CPAP) was introduced more than 30 years ago for infants with respiratory distress. With this, there had been reports of decreased incidence of mechanical ventilation and chronic lung disease among the premature, as well as less failure of extubation. This report described how this treatment modality was adopted locally and showed it might be associated with less apnoea among very low birth weight (VLBW) and extremely low birth weight (ELBW) infants post extubation with improved non-pulmonary outcomes. Key words Apnoea of prematurity; Bubble CPAP; Chronic lung Disease; ELBW babies; VLBW babies Introduction device. Pressure can be generated from the following three ways.4 Continuous positive airway pressure (CPAP) is a method Firstly, the expiratory valve of the ventilator is used to of delivering positive end-expiratory pressure with a adjust the expiratory pressure. Secondly, the pressure is variable amount of oxygen to the airway of a spontaneously generated by adjusting the inspiratory flow or altering the breathing patient to maintain lung volume during expiration, expiratory resistance (e.g. Infant Flow Nasal CPAP system, so as to reduce atelectasis, respiratory fatigue and to VIASYS Healthcare, Inc. USA). Thirdly, the bubble CPAP improve oxygenation. It was first reported in 1971 for system produces a positive pressure by placing the far end supporting breathing of preterm neonates.1 Clinical benefits of the expiratory tubing under water. The pressure is have been associated with the use of CPAP in the premature adjusted by altering the depth of the tube under the surface newborn. Even in the pre-surfactant era and when antenatal of the water. steroid usage was uncommon; there was some evidence In the seventies, Dr. Jen-Tien Wung at the Columbian that early application of CPAP might reduce subsequent Presbyterian Medical Center, New York developed the use of mechanical ventilation and the associated adverse bubble CPAP system using short nasal prongs. In 1987, outcome.2 Infants extubated to nasal CPAP experienced a Avery et al5 published a retrospective study of 1625 reduction in respiratory failure necessitating assisted neonates at eight tertiary centers. Columbia University, ventilation.3 where the predominant mode of respiratory support was CPAP system consists of a source of humidified blended the use of nasal CPAP, had the lowest incidence of chronic oxygen, the pressure generator and the airway interface lung disease (CLD) without any significant difference in mortality. Department of Paediatrics and Adolescent Medicine, United Christian Hospital, 130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong, China The Bubble CPAP System KM CHAN RN, RM, MSc(Nursing) Essentially, the bubble CPAP system consists of three HB CHAN MBBS, FHKAM(Paed), FRCPCH components: a continuous gas flow into the circuit, an Correspondence to: Dr HB CHAN expiratory limb with the distal end submerged into a liquid Received February 15, 2007 to generate positive end expiratory pressure,6 and the nasal Chan and Chan 87 interface connecting the infant's airway with the circuit without leakage, it results in continuous bubbling and (Figure 1). As the gas leaves the circuit via the expiratory the pressure oscillates in the circuit.9 Leakage is not limb, it bubbles (Figure 2). obvious in ventilator (Infant Star) CPAP. Though the Oxygen blender connected to wall oxygen and pressure oscillation was once suggested to facilitate gas compressed air supply is used for supplying appropriate exchange,10 this postulation was not supported in another concentration of inspired oxygen. Optimal gas flow is recent report.11 maintained with a flow meter to prevent rebreathing of Short binasal prongs are commonly used for the nasal carbon dioxide, increased work of breathing related to interface between the circuit and the infant's airway as they insufficient flow available for inspiration and to compensate are found to have the lowest resistance12 and their use has for leakage in the CPAP system.7,8 Flow rate of 5 to 10 been supported by a meta-analysis as the better device for liters per minute is optimal for CPAP delivery in the delivery of effective CPAP.13 Choosing the right prong and neonates.8 keeping it in place not only increase the effectiveness of Pressure in the bubble CPAP system is created by placing CPAP support but can also prevent nasal trauma. The the distal expiratory tubing in water. Designated pressure resistance increases proportionately with increasing length is determined by the length of expiratory limb being of the prongs and exponentially with decreasing radius. immersed.8 When the pressure is delivered to the baby Shorter and wider binasal prongs that can fit snugly in the nares without causing blanching of the skin is a good option. Hudson (The Hudson RCI infant nasal CPAP cannula system, Teleflex Incorporated, USA) and Inca (Ackrad Laboratories, Cranford, N.J., USA) prongs are similar in design. Similar sized prongs (actual measured size, not nominal size as designated by the manufacturer) of either type are likely to have similar resistance. Inca prongs are straight, whereas Hudson prongs are anatomically curved. Theoretically, the latter might fit the airway better, directing the flow more appropriately down the airway. Nursing Care of Infants on Bubble CPAP Elaborate nursing care is pivotal for the success for applying bubble CPAP to premature infants. Proper Figure 1 The nasal interface positioning of the prongs can be secured by putting on an appropriate size hat which rests along the lower part of the infant's ears and across his forehead with the circuit fastened on it. It has to be snugly fitted and stationed on the infant's head, otherwise the circuit and the prong will move with the motion of the loosely fit hat. Tissue necrosis was observed if one was unable to keep the prong in the nostrils of an active infant.14 Nasal trauma is common when the prong rests on the septum of the nose or on the columella.15-17 Application of a Velcro mustache placed over a piece of Duoderm on the philtrum can prevent the accidental incarceration of the prong onto the nasal septum or the columella. Besides, adequate airway humidification and gentle nasal suctioning is paramount in maintaining a clear airway without jeopardising the tissue integrity of the nostrils. Figure 2 The expiratory limb Lightweight ventilator circuits with dual heated wire 88 Use of Bubble CPAP in Premature Infants (e.g. Airlife, Allegiance Healthcare Corp., USA) and October, 2000 and end of March, 2002 (Period 1) were servo-regulated humidification system is necessary for compared with those born between October, 2002 and end the delivery of warm and humidified inspired gas to the of March, 2004 (Period 2). Babies with major congenital CPAP supported infant.18 "Rain-out" (condensation) anomalies such as cranio-facial cleft or requiring transfer affects the gas flow and resistance. It should be checked to other centres for various reasons were excluded. and drained regularly. The probe and chamber This study aimed to evaluate the following respiratory temperature and the positioning of the temperature probe outcomes after the change: can be manipulated to minimise the "rain-out". 1. duration of mechanical ventilatory support Consistent bubbling is important to recruit alveoli, 2. number of infants who required mechanical ventilation maintain functional residual capacity, and reduce airway within 24 hours after extubation (failed extubation) resistance and work of breathing, especially in the early 3. duration of CPAP support acute phase of respiratory distress. If the bubbling stops 4. number of days with significant apnoea (cessation of ≥ it means that there is a pressure leak in the system, respiration 15 seconds with SaO2 <50% and associated usually around the nostrils. It has been reported that the with bradycardia, heart rate <100 beats per minute) pharyngeal pressure drops markedly when the CPAP during CPAP supported infant opens his mouth.19 Recent study 5. duration of oxygen therapy demonstrated that the prong pressure, though not totally 6. the postmenstrual age (PMA) of the infants when transmitted to the pharynx, was more effectively oxygen therapy was terminated 20 transmitted when the mouth was closed. The use of chin 7. number of infants requiring FiO2 >30% at PMA of 36 strap or pacifier has been recommended to reduce mouth weeks. leak for effective CPAP support.20 However, it should not be so tight as to prevent the infant from yawning or The non-respiratory outcomes were also reviewed which crying but tight enough to prevent leaking at rest. included: The infant's respiratory status has to be assessed at 1. duration on total parenteral nutrition (TPN) regular interval to evaluate effectiveness of the treatment 2. postnatal age of the infants when full enteral feeding and plan for subsequent care. CPAP has to be temporarily was tolerated interrupted during chest auscultation as the bubbling sound 3. number of infants with necrotising enterocolitis (NEC) may interfere. However, caution has to be taken as the infant 4. number of infants with grade 3 to 4 intraventricular may present with apnoea and bradycardia when CPAP hemorrhage (IVH) support is suspended for just a brief period. 5. body weight at PMA of 36 weeks Gastric distension is common in the CPAP supported infant (CPAP Belly Syndrome).21 Frequent decompression During both study periods, there was no major change of the stomach with an oro-gastric tube is necessary to in technology and medical management of the premature promote comfort, preventing the distended stomach from infant in the unit. The only difference was the use of bubble splinting the diaphragm and compromising respiration. CPAP in Period 2 which substituted for the ventilator (Infant The bubble CPAP system and practice of the Columbia Star, Tyco Healthcare) CPAP support in Period 1.
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